Provider Assisted Death By Prescription in the United States: Part I #525

Background

Provider Assisted Death by Prescription (PAD-P) describes a provider prescribing a lethal medication to a competent, terminally ill patient who self-ingests it for the purpose of hastening death. ¹ In the United States, this practice is legal in some states and often labeled Medical Aid in Dying (MAID), Physician-Assisted Suicide (PAS), or Physician-Assisted Death/Dying (PAD), terms that can be controversial, confusing, and/or euphemistic.^1,2 For example, in Canada, the acronym MAID stands for Medical Assistance in Dying but on a practical basis refers to voluntary active euthanasia (the administration of a lethal medication by a clinician), which is illegal in the United States. For the purposes of clarity, we will utilize the term PAD-P in this Fast Fact. Providers should be prepared to discuss the topic of PAD-P knowledgeably, regardless of personal views. This Fast Fact discusses state law commonalities, eligibility criteria, epidemiology, patient demographics, and reasons for PAD-P requests specific to the U.S. Ethical, clinical and practical considerations of PAD-P in the United States are discussed in Part II of this Fast Fact.

Core Commonalities and Eligibility Criteria

PAD-P has become legalized in a growing number of U.S. states (though certainly not all) since the enactment of the first law in Oregon in 1997. While state laws vary, most are modeled on Oregon’s original statute and share similar patient eligibility and process requirements listed below. ³ Providers should know the specifics in their state (including if a state takes a non-statutory approach), and this Fast Fact does not provide legal advice.

Age ≥ 18 years or older.

Other requirements of PAD-P more often vary by state: ³

Mandatory waiting periods.

Epidemiology

It is challenging to accurately track PAD-P deaths in the United States because reporting requirements and data collection vary across states. Death certificates cannot be used to track PAD-P, as they list the terminal illness, not PAD-P, as the cause of death. Available data suggest that across jurisdictions where PAD-P is legal, PAD-P deaths make up less than 1% of total annual deaths, though rates vary by state, and rates increase as laws mature.^4,5 Aggregated data from nine U.S. jurisdictions over 23 years (1998–2020) show that patients who use PAD-P are typically older (median age 74) and predominantly non-Hispanic white; slightly less than half are women; most have some college education; and cancer is the most common underlying diagnosis. ⁴ Available reports suggest that most patients who use PAD-P are enrolled in hospice and/or palliative care services at the time of death.^4,6,7

Common Reasons for Patient Requests

A widespread misconception is that patients most often request PAD-P due to intolerable physical pain or other illness-related symptoms. While true for some, ⁸ data indicate that the most common reasons behind PAD-P requests include loss of autonomy, impaired ability to participate in enjoyable activities, fear of being a burden, and wanting to control the time and manner of death.^9–11 Some patients cite the fear of developing intolerable pain or symptoms in the future, ¹² and request PAD-P as a “backup” option in case their condition worsens. Roughly one-third of patients who request PAD-P end up not using it.^5–7 It is important to be aware of the reasons behind PAD-P requests, which patients in an emotionally vulnerable state may not verbalize initially. Exploring these concerns, providing reassurance about the dying process, and ensuring referral to hospice and/or palliative care services may provide great benefit and relief of the patient’s concerns. See Fast Facts #156 and #159 for how to respond to requests for hastened death.