Welcome, everyone. Thanks for joining today. We're going to go ahead and get started and people will continue to join throughout today's session. My name is Gina Parisi and I serve as HMDCB's Executive Director and we're really excited to have you all here today for our June Coffee Chat. And just a reminder that we really want to make this as interactive as possible, so please feel free to come off mute to ask questions or you're welcome to put questions in the chat box as well. So before we get started today, I just want to share a couple HMDCB updates with everyone. So the Hospice Physician Compliance Conference is taking place July 12th. That will be hosted by Weatherby Resources. You can use the discount code on the screen to receive 10% off the registration fee. And then the next HMDCB webinar will be held in August and it will be focused on navigating hospice audits. So we encourage everyone to register for free. It will take place on August 21st. And then, of course, you can view all upcoming HMDCB community events at hmdcb.org slash community. And a reminder to anyone whose credential expires in 2024, you can renew it by participating in our new continuing certification program and you have until October 31st to complete that process. And just a quick reminder that all webinar and coffee chat recordings, including today's session, are now being hosted in our new learning management system, the Certification Center. So we'll send out an email after today's session with instructions on how to create a free account and access all of the recordings. So I want to quickly introduce our facilitators for today. So we actually have two facilitators joining us today, Dr. David Wentzel and Dr. Robin Plummer. Dr. David Wentzel is the current board president of HMDCB, as well as the chief medical officer at True Community Care in Colorado. He has helped them grow their hospice, palliative medicine, PACE, and home health programs. Dr. Robin Plummer is a current HMDCB certificate and has been participating in the New Jersey Medical Aid in Dying program since August of 2020. She and her partner have advised hundreds of patients about MAID through their practice, Compassionate Endings NJ. And Dr. Plummer is an educator and advocate for MAID as an option for terminally ill patients. So we will focus today's coffee chat on MAID, but if you have any hospice-related questions, please feel free to ask them. Dr. Wentzel and Dr. Plummer, thank you so much for being here with us today, and I will now hand the conversation over to you. Thanks, Gina. It's great to be with everyone today, and I'm so looking forward to the conversation and the chats and questions. So first, Dr. Plummer, if you want to give a brief sort of intro to your role and what you're doing, maybe we'll start there, and then I can talk a little bit about what my role is and how we interface with MAID in Colorado. So thanks for being a part of this. You're welcome. I'm just wondering, I see some people, well, I see a lot of pictures. I don't see any actual faces. So if I ask a question, I kind of wanted to know how many people here know very much about aid in dying, and if they know much about the qualification procedure. Is there a way you can just like raise your hand, even if I'm not seeing your face? Or turn your camera on and wave at me. I see a couple of hands. Yeah, I see a couple of hands raised there. One of the reasons that we thought we would do this session today is because I'm under the impression that many people don't really know very many details about aid in dying. And again, I'm from a state that passed the law in 2019, and my overall impression in speaking with docs all the time is that most of them don't know much about it. In fact, even in New Jersey, where this passed in 2019, I would say the greatest, the most common reaction I get from doctors that I might call to ask them about being consulting doctors is, what? That's legal in this state? So for those who don't even know about it in their own state, I have to believe that in states where MAID is not currently legal, you might not know too much about it. So just to give you a little background, I was actually an emergency doctor for 35 years. I then switched over and trained in hospice palliative care. And I was actually living outside the country for 10 years, and I didn't know when New Jersey was trying to pass the law, I didn't really know anything about it. And when I came back from overseas, I heard from my hospice that this new law passed called medical aid in dying, and they gave a nice little seminar about this is how it works. And then the last line of the presentation was, and none of our doctors are allowed to participate. So I thought, oh, well, that's kind of interesting. I wonder where patients go. About six months later, I left that hospice and I started looking into it myself. I thought, well, if I were a patient, and I wanted to access it, how would I find a doc? What I found out is it's really, really hard to find a doctor. And even now, even for me being having doing this now for four years, it's still hard. Part of that's because I can't have a billboard on the New Jersey Turnpike. Part of it is I have a website. And of course, my website does not show up very high on Google because Compassion Choice and Death with Dignity have the top ranking. And part of it is I don't want to be too out there because I do sometimes worry about sort of crazy people who might find me too easily. So ultimately, what's happened is that people generally do find me through hospices. But even that is a challenge. I give lectures all the time to different kinds of different hospices, and I've often had to repeat my presentation every year or so because the staffs change. And what you find is for individual patients who ask about aid in dying, it depends who they ask. If they ask a nurse who's familiar or a social worker who's familiar, they'll get one answer. But people get the wrong answer a lot of times. And if they're getting the wrong answer from hospices in a state where aid in dying is legal, I just can't imagine what answers they're getting if they ask in other states or if they happen to get someone who doesn't know much about it. So again, just as a little background, since I was an emergency doctor, I just want to say that over the course of my career, I saw a lot of what I would describe as bad deaths. You know, I saw people who showed up in the ER with either injury or illness, but they didn't anticipate the imminence of their dying. And they didn't have much opportunity to say goodbye to the people that they love. They were pretty traumatic, terrible deaths. So switching over to hospice was interesting because obviously we were able to discuss that more and provide more comfortable deaths. But there's a certain number of people in hospice who dread the thought of a long, drawn-out death. And contrary to what you might think, it's not generally because they don't get good pain relief. In the beginning, people will say, I don't want to be in pain, I don't want to die in pain. But later, what they often say is, I don't want to be unconscious and have my adult son or daughter wiping my bottom or be unable to bathe myself or communicate with my family. So when I decided to get into medical aid in dying, I found there was a really supportive community that was really based in Oregon, Washington, and California. Oregon, you may know, has had aid in dying for, I think, 24 plus years. They were really ahead of the pack in all of the other states. But many things have changed since Oregon started. For example, the medications that we use, which I could go into with a different lecture, but now we use quite a different cocktail. And I do want to say that the group, which is called ACA Made, which stands for American Clinician Academy for Medical Aid in Dying, is an amazing group that focuses on clinical aspects. It doesn't focus on passing the law or changing the laws. That's compassion and choice. But they are clinicians. They're the ones who provide information to anyone who participates, whether it's nurses, social workers, doulas, medical aid in dying doctors. And they are really a supportive group. Somebody put it up there. Thanks, Gina. We also have a hotline where six of the more experienced made doctors, and I'm one of them, we take call every six weeks from anyone across the country, any clinician. Not meant for families or patients. But to answer questions about whether it's qualifying someone for made or complicated situations or even problems at the bedside. We can do that, too. So ACA Made is a great resource to know about. So what I think I'd like to do is, if it wouldn't be too redundant, I'd like to just talk about the general process that people have to go through. And I'll say a little bit about how it varies state to state. So I can't see you guys nodding. But for those that I can see, is that okay? Is that what you like to hear? Okay. So the laws are pretty similar across the 11 states. There's basically 10 states plus D.C. right now where medical aid in dying is legal. And the biggest difference between the U.S. and other countries that have aid in dying, like Canada and, of course, some of the European countries, Australia, New Zealand, is that in the U.S., the patient must ingest the medication through the GI tract. And by the way, one of the distinctions between medical aid in dying or physician assisted dying, we don't like the word physician assisted suicide at all. One of the distinctions is that people must self administer. You may be familiar with some organizations like Dignitas or Pegasus in Switzerland where people can go and they can actually apply for euthanasia. That means somebody puts an IV in, somebody else pushes the medicine, and that is euthanasia. It's still physician assisted dying. But in the U.S., it's got to be self administered. Generally orally, however, there are people who can't swallow, particularly ALS patients, people with upper GI cancers. We can use peg tubes, we can use colostomies, and we can also give it rectally. Well, we can't give it rectally. The patient gives it. Someone else can place a rectal tube and basically feed it through the person's leg so it sits in front of them at their umbilicus, put the medicine in the syringe, but the patient themselves must push the syringe to self administer. And that's a fairly common technique that we use for ALS patients. Anyway, the process basically is that it takes in most places a minimum of 16 days. And this is changing. Some of the states have now shortened that, like California and New Mexico have shortened that to 48 hours, which is really quite a big difference. Other states, I believe, Oregon, allow for the doctor to apply for a waiver if a patient can't make it through the 16 days. Now, in New Jersey, which is kind of a prototype, you have to have two doctors. One is called the attending, but is better described as the prescribing doctor. That would be me. And the patient has to do two verbal requests, and these have to be face-to-face encounters. They can be in person, they can be telemedicine, they can't just be a phone call. During which time I ask people a series of questions, following a discussion, of course, right? I mean, I do a whole hospice evaluation, and a discussion is made. And then I ask them, you know, their demographics. Are they a New Jersey resident? Do they understand their diagnosis? Do they understand that they have to have a prognosis of less than six months? I ask them to explain MAID to me so that I know that they have a good understanding of what they're asking for. I ask them if they feel they can make this decision with a clear mind, and whether they're being coerced by anyone. And, of course, I'm making my assessment about whether I feel that they can make their own medical decisions. Because this is not available to people with dementia who cannot make the clear medical decisions for themselves. And whether or not they're on hospice, and whether they've told their family. So I have kind of a series of questions that I ask people. And, in fact, when I refer to a consulting doctor, I send what I think is a pretty clear letter to the consulting doctor saying, these are the suggested questions. You can copy-paste this in your own notes. And then I explain to them how to fill out the New Jersey consulting doctor form. Which is not difficult, but is also not very well constructed. So it needs a lot of explanation about where to check and where to sign. And I don't know what the other states' forms look like. So after I take a first request, then this sets the rest of the qualification process into motion. And the minimum period of time that it can take for somebody to qualify, as I said, in New Jersey is 16 days. Day one and day 15 are the requests with me. In that intervening two weeks, they have their consulting doctor visit. I have to obtain their medical records to confirm that their diagnosis that they told me about is correct. Confirm their prognosis. And then they have to do the New Jersey state paperwork. Again, it's pretty standard among the states that people need to do a written request. In New Jersey, it's called the request to end my life in a humane and dignified fashion. And it's a very easy form for the patient to fill out. They just check off a few boxes like I'm on hospice and I've told my family. But it does require two witnesses. And when I started doing this, I didn't realize that getting a non-family member witness might be a challenge for some people. But it is because not everybody wants to tell, you know, people outside of their immediate family. So I learned that there's a thing called mobile notaries. And you can have a mobile notary come and be the second witness. One witness can be a family member. The other has to be somebody that has no interest in the patient's estate. And the witness is not saying that they agree or disagree, by the way, with aid in dying. The only thing the witness is saying is they can identify the patient. They see them sign the form. And they're of sound mind, meaning that they're not in a coma and that they're not the patient's own doctor. So that's what the witness does. So those are kind of the steps. And the way I run my practice, and I work with a nurse who's also a former ER nurse, we sort of shepherd people through the steps. You know, this is how you fill out the paperwork. I'm the one who makes the phone calls to the consulting doctors. I don't think it's fair to make the patients do that. Sometimes I get a list of their doctors, you know. Give me your oncologist, your family doctor, your GI doctor. I may make several phone calls to try to explain to the consulting doctor what they need to do. And this is how I know that there's a lot of doctors that don't have any idea about what aid in dying is, because I get so much surprise. And a lot of what I'm doing is explaining to them what their role is. Now, for many of these potential consulting doctors, once they get past the hurdle of, oh, this is actually legal in New Jersey, what they really want to know is that they don't have the responsibility of writing the prescription or following up afterward. And that's fine, because, again, I do that. That's how I've created my practice. Again, what they need to do is just make sure the patient knows what they're asking for, confirm that they feel that they're of sound mind to make their own decisions, and then check off the form. So assuming they get through the 15 days, and this, by the way, is, to me, is one of the biggest problems with our law in New Jersey, and some of the other states are changing this. As I said, some states will permit a waiver for patients who might not be able to make it through the 16 days, because for those who come to me too late, it can be really, really sad if they don't make it through the 15 days, right? However, in New Jersey, you have to make it through the 15 days, and then I can write the prescription, but it can't be available before day 16. Now, there's a small number of people, I'm going to say maybe 20%, who say to me, the minute I can get my hands on that medicine, I want to get it. And that's fine, as long as they let me know in advance. I don't want anybody calling me up and saying, you know, I had a really bad night, so tonight's my maid day. No, no, not how it works. I tell people from the outset, this should be a careful, thoughtful, considered decision. That's like in a perfect world, and that is usually how it is. Once in a while, people will have a medical emergency or a crisis, and they have to move it up quickly, and our pharmacies are very accommodating. I also would like to mention my partner and I make it a point that we attend every death. Now, this is not written into any of the laws, but again, through ACA Maid, as this is kind of evolving a bit into a specialty, most of us feel that the best medical care would be to support the patient on the day that they're going to self-ingest the medicine. And it's not really that easy. First of all, it's a huge responsibility for the family. Just touching this medicine, it comes as a powder. It's five different medications mixed together in powder form and they need to be mixed with two ounces of liquid, usually apple juice, and then the patient needs to drink that in under two minutes. Unfortunately, the medicine doesn't taste very good. Actually, it burns and it has a bitter taste to it. Some people are more bothered by that than others. I haven't ever had anybody who literally said that they couldn't drink it and people do get it down, but we kind of coach them through it and the technique we use is we alternate them taking either sips of a fruit sorbet or sucking on a popsicle. So it's kind of an alternating thing. So just to kind of give you the picture, I'm sitting in front of the patient. They're sitting, say, either in a recliner or maybe with their legs over the side of the bed. I'm directly in front of them. I have the little bottle with the medicine. I hand it to the patient and I actually give it to them right in that little medicine bottle. I don't even put it in a glass because more chance of spillage, right, the more times you're, you know, decanting this stuff. Someone else sits next to me. They start out with the sorbet. I hand them the bottle. They take as many sips as they can. Some people drink it right down. Other people, two sips, sorbet, two sips, sorbet, and then, as one of my patients said, end on dessert, right, and they get as much sorbet as they want. I've had people lick the plate afterward, okay. Then they will fall asleep within five to ten minutes, sometimes faster. So they need to be not sitting in a chair where they're going to have to get up and walk into the bed. They need to be in a place where I can either just lay them back, which is why recliners are great, or sitting with their legs over the side of the bed so we can quick flip them up if they start to fall asleep really fast. Now, again, ACA Made is collecting a lot of data on a lot of these deaths so that we know a lot about, you know, just general stuff like, you know, age, sex, diagnosis, time to sleep, time to death, complicating factors, and we know from collecting over a thousand cases at this point that 80% of people die within two hours and 90% die within five hours, and we also know that certain diagnoses put people at risk of having a longer death. Now, the thing is this. No one's going to wake up. It's not going to be that relevant to the patient, but it's really important to the family, right? If they're told two to five hours, somebody, and I've had some very long deaths. Usually it's people who have absorption issues. Like one of my longest deaths was a lady who had ovarian cancer with ascites, and we did rectal administration, and I just think there was so much pressure in her abdomen she just didn't absorb it too well, and other people have repeated the same kind of findings. Also, although I can't explain this in any way as a scientist, people who have complicated social situations, like people who maybe have children or family members who might not be really in accord with aid in dying, sometimes have a longer period till death, even though they should be deeply comatose. I don't know how they know, but you've all seen these stories in hospice. So, I think the important take-home points here are that I get a lot of patients who call me who say, oh my gosh, it takes months to qualify, right? No, it doesn't. It's usually 16 days or less, depending on the state. I do want to say something about the residency issue because this is a big topic right now. In the past year, Oregon and Vermont have now lifted their residency requirements, so anyone from any state can go there. However, they really do have to go there, okay? So, you can't call from Kansas and say, oh yeah, I'm in Vermont, right, and then go through the whole procedure and then get your medicine sent to you and take it in Kansas. No, you've got to be in the state for all of the steps, meaning all of the visits, and most importantly, you must be in the state when you take the medicine. Now, New Jersey is right now trying to lift their residency requirement, and I'm kind of not that hot on it because I don't think that's really the big issue. Frankly, in New Jersey, it's not that difficult to achieve residency. Again, in New Jersey, at least, you don't have to be a resident for any specific period of time, but you have to have the right documentation, which in New Jersey is a voter registration card. It takes about two to three weeks to obtain that. The bigger problem I've seen is having a place to go. I have not had a lot of patients come from other states, but I've had inquiries, and I have had a handful of people from Pennsylvania and New York or neighboring states, and the biggest issue is where are they going to go. Now, if they have a friend or a relative who lets them claim their home as residency, that's fine for getting the New Jersey voter registration, but once the patient actually wants to go to their house to die, you can imagine some relatives are maybe not so hot on that idea, even though it's not a crime scene, right? There's not blood and guts spattered all over the wall. It's very quiet. They drink their medicine. They fall asleep. It still scares people, so I have had people who have, and you can't do it in a public place, by the way, so you can't sit on a park bench or be on the beach either. I've had people rent a condo or an apartment for a few months. I've had people rent an Airbnb, which always feels a little bit weird, but it's kind of legal. I don't ever want to go to a hotel or a motel because that's a whole big medical investigation, medical examiner investigation if someone dies there, so the bigger issue really is where do you go if you go to another state, and of course, this leads back to the whole question about why is there even requirements that you have to be a state resident? I mean, if you live in New Jersey, you can go to New York for your cancer treatment. You can go to Pennsylvania for your ALS treatment, so why do we have that restriction at all, so I could keep talking for the whole hour, but I'll pause here and get some questions, and then I can tell you some stories if you'd like. Do you want me to click on the chat, Gina, or do you want to read them? I haven't seen anything come through. I just want to encourage people, if you do have questions, please feel free to come off mute or put them in the chat box, and also, Dr. Munsell, if there's anything that you would like to share about your experience, please feel free to do so. Yeah, I'll talk a little bit about Colorado's, so Colorado enacted their end-of-life options act in 2017, and they updated it this year, so the governor just actually signed the update, so the state of Colorado reduced the waiting time from 14 days down to seven days, and they also now are going to allow advanced practice providers to do the evaluations, so as it is in New Jersey, two providers have to confirm by evaluation, face-to-face evaluation, that the person requesting it meets all those criterias that Dr. Plummer just mentioned, terminal condition and having capacity and all that sort of stuff, and here, like there, people who choose that must be able to self-administer, and so I think the process is very similar, it's just the only change that's been made recently in Colorado. They did try to remove the state residency requirement in Colorado, but they couldn't get that through the legislature, so the only change was dropping from 14 days to seven days, and now working through a process of allowing advanced practice providers to do the evaluations, so I am the chief medical officer of a large non-profit hospice in Colorado, and we, our organization, True Community Care, like the American Academy of Hospice Palliative Medicine and American Academy of Family Physicians, we have always taken an approach of engaged neutrality, where we don't actually do the evaluations or write the prescriptions, but when someone in our hospice care or even in our community palliative medicine program asks questions about it, we do provide them with the resources of where they can go, and three of the large healthcare organizations in the state of Colorado have a process set up where they can have an attending and a consulting provider who will do the evaluation, so it's, it's not as difficult maybe here as it sounds like it is in New Jersey, because it's, it's, it's the, the, the three, three of the major healthcare organizations here have a system already set in place. They have providers who, who will do the evaluations and serve as the attendings, and we just simply provide the resources. When asked, we always provide the family or patients or caregivers with the resources so that if they want to pursue it, they can. We certainly, you know, assist them if needed in terms of helping them, you know, where they need to go and that sort of stuff, so, but, but our organization chose engaged neutrality because about 40 percent of our referrals come from faith-based organizations that, that won't allow or don't support it, and so we, we just stay neutral in that we will provide the resources if needed, but, but don't actually participate in the evaluations or write in the prescriptions, you know, and, and our physicians and the physicians here in the state of Colorado who do the evaluations and the attendings or the consulting providers, as far as I know, none of them have ever attended. They've never been at the, the patients, and in fact, it's ultimately, it lands on us, the hospice, to actually provide support to the patients and families, which we always do. It's not always possible for one of our providers to be there when they, when the patient decides to ingest the cocktail, but our nurses are always available, social worker shop, our entire interdisciplinary team is available to the families and the patients if, if, if it's appropriate, and the other thing that we always do is engage, if they're, if the families, patients, caregivers are interested, we always engage our bereavement services early, way upstream of all of this so that they have connection to bereavement services because that's another big sort of piece of this. My experience so far, I've been in Colorado four years, and I would say not scientific in any way, but approximately 30% of the patients who we've cared for in our hospice, who requests made and get the actual prescriptions, don't actually take it. They, they have it and they have it in their homes, but they either progress too quickly and can't self-administer, or they just choose not to. They just want to have it there in case as an option, if there's something they want to do. And so here, like many states, we, we don't list, you know, use of made as the cause of death on the death certificates. Most of the research, and there's been a lot of it done here in Colorado, are often done by post-death surveys of the families and that sort of stuff, which is not, not the most ideal way to look at that information, but that's sort of the best we have. So we don't have, from Colorado anyway, we don't have great statistics really on the total number of people who actually ingested and because, you know, not all the hospices here in Colorado support it. And the other issue that Dr. Plummer was talking about that we run into here a lot are locations. So if we have a patient that we're serving in a particular nursing facility, the nursing facilities won't allow it in the facilities often. And so again, it's, it's always a tricky thing about where the residence is. Now, you know, again, Colorado, in order to access it here, like New Jersey, you have to have residents here. Because I, I believe, as you said, I think there's only two states that have waived that. And it came up, but it wasn't supported enough in the legislature to get that written into the update to the End of Life Options Act here in Colorado this year. So we've just always taken an approach of supporting patient family wishes and helping them if they're, if they're, if they want to pursue that, we provide them with the resources and also make sure they're supported through the process. So that, you know, there's not the, the idea of abandonment, as it were, from the medical providers and the hospice, if we're caring for them. But we do have local hospices who won't participate at all. And we'll, if a patient's requesting that, they'll often refer them to our hospice, or there's a couple of others in our state that do. And so that's, that's the, that's, I think the, the way is that many of the states are sort of trying to grapple with how do you make sure your, the patient's families are supported, not just from the request time, but all the way through into bereavement with the family members and such afterward. So I think that's it. And it looks like Kishonna has, is it a question? Somebody's leaving. Well, there've been a couple of, yeah, and you're right. There was a couple of really good sessions at the AHPM Annual Assembly in Phoenix. I attended both of them. There was a large group from Oregon that presented a really good discussion about this at the AHPM meeting this past March in Phoenix. So. So I wanted to just say something about the attendance issue. Again, those of us who are practicing aid and dying regularly, I can tell you that I've attended about 160 maid deaths, me personally, which is probably more than most people in the, in the U.S. It's a pretty big thing to ask a family to do that. I mean, I just can't think of any other medical procedure where we would make this really toxic medicine available to families and just say, here you go. I hope it goes well, right? There's, when I, when I attended death, I kind of go in with two hats on. One hat is I'm here to be the safety person. Like I'm going to make sure nobody touches this, as I said, other than the patient and me in a closed system. I worry about if it gets mixed in a glass and there's a little bit of apple juice sitting on the table that the three-year-old granddaughter might walk by and go, hey, I'll have some apple juice. I worry that the dog will jump up on the bed if someone's drinking it and knock their elbow and it'll go spray all over everybody. I worry about what did they do with the spoon after somebody's been eating with the sorbet, because don't think I haven't seen a wife who handed her patient, her husband, a Popsicle after he had ingested, she handed it, he handed it back to her and she went to stick it in her own mouth, right? After it had been in his mouth. So part of me is really on the alert and I realize that's the ER doc in me, right? But I want to make sure that there's no errors that occur. And the other part of me is I'm there to support the family and just free them to just be the family and not be where, I mean, if I was the daughter and I wasn't medical and I knew I was the one who had to mix that medicine and handle lethal potion to my dad, I think that's a pretty big burden to put on people. So I do think this field, sorry about all the dog noises behind, I have like four dogs in my house right now, visiting. Of course, they have to all bark now. Anyway, I do worry a lot about the effect on the family. It's already a stressful enough day. They already want everything to go well and not have to worry about the details of it. So I feel like that's something that we should take that burden away from them. Now, there are some states where they have doulas, or I think Oregon and Washington have trained volunteers. They're not medical, but at least they're people who can, again, mix the medicine, hand it to the patient and hopefully reassure the families, particularly if there was the case of a long death or if there was a very unlikely, again, I can switch hats. I rarely, rarely have to use my plan B, but if I were there and if the patient for some reason didn't ingest enough or vomited and there was a problem, I can put my hospice hat on and administer hospice doses of medication, right? I don't know what a non-trained volunteer could do. So sorry about the dog noises. Anyway, I could just talk on and on about this, but do you guys have some questions or is this new information to you? As with Tommy Farrell, it's not new information, but you made the comment that there's nothing else that we require families to do directly like this, but this is unique, right? And this is why also saying this should be a medical responsibility is a very large switch from what we, most of the people I'm seeing on this call are at least my age, and this is different than what we were trained as a purpose of a doctor. So there's also, the reason why it's different, and we can, I don't mind if a physician chooses that this is going to be an area that they can do, but to say that it should be the norm to make sure this is administered by clinicians would potentially limit more because there's going to be more and more locations where if I'm asked in this city where there's not as many palliative care doctors, if I'm asked, I'm going to be like, this is not a practice that I accepted would be something I would do because there's nothing else that I do that administers a medicine to end the life of the patient. So I have to get over that, have to get over that hurdle that that is going to become a correct thinking for a clinician that's not only been trained that way, but feels strongly about the, that that's different than anything else I administer. Nothing else do I ever administer is for the purpose. I was asked when I was in my, in fact, on my training days, we all probably remember for those in the palliative care field, how much we were talked about how careful to be when we are offering palliative sedation and how that had a very deliberate process to it. And so to jump from something like that, where I'm supposed to be very careful to do that, to saying, okay, any less careful on, on the next step is something that is just a bigger leap. So that's why I say this is something different because in palliative sedation, I've at least been able to say my purpose isn't to end life. The purpose of this medicine is to make sure the life ends at that time. So that's, I just bring that up that this is different to say, well, why are we putting this into a different category for medicine? It is a different action of medicine. Yeah. And I agree that there's going to be areas in the country where there are people are not always going to have access, but it also doesn't mean, again, I think the best thing is to have an attendant present, but there have been people who have used telemedicine or been available by FaceTime, at least to support the family, you know, to watch them mix it, to watch them present, to give reassurance when the patient goes through changes, like they have color changes, they have funny breathing patterns. That would be pretty terrifying, I think, to a family that's not used to seeing someone die. In fact, even as hospice doctors, I mean, again, I was a hospice doc for about seven years and I worked in an inpatient unit. I probably saw more actual deaths than most hospice doctors, but many don't. The nurses see more than the docs. I don't know for you guys, has anybody here seen more than 10 where they've literally been at the bedside? It's quite scary, right? And you need sort of a guide there. Right. That's why if we made the dying process needing a doctor's attention, I mean, I would be all for that. You know, I try to attend as many of my deaths as I can. Like you say, that process is scary, whether it's through this process or any process of dying. Unfortunately, we don't have the current manpower for physicians to be at every attendant death. We count on the nurses for that. We really count on the nurses for that. Right. And as I said, End of Life Washington in Oregon, they have apparently quite a robust volunteer group where they've trained volunteers to be present at maid deaths. And at least they can call the doc if there's a complication, which is good. But you know, there really are a lot of parallels between birth and death. Right. There's so many parallels. And we don't generally ask people to give birth by themselves or for the families to handle it like it's a pretty big deal. It's a pretty big passage in life. So, you know, look, this is not going to appeal to every hospice patient. And this is one of the big questions, too, is should this be offered to everyone when they come into hospice? Should you say in a maid state, oh, by the way, you're coming out of hospice, just want to let you know in New Jersey you can have medical aid in dying. Well, some people think you should say that. I don't necessarily think that would go over all that well. But it's that small number of hospice patients that start to ask their team, oh, my gosh, I don't want this to go on forever. You know, you know, the question, isn't there anything you can do to make this go faster? That's the question. Right. And typically that's where you would offer if you were a hospice in a maid state. Well, did you know that there is an option in the state for medical aid in dying? And I bet most patients at that point say, what, that's legal in the state because their doctors don't know it either. And only people who have really searched it out really know much about it. So that's kind of an opening. I mean, look, hospice philosophy worldwide is we treat the symptoms. We don't make anybody die faster or slower. That's pretty much hospice all across the world. I've worked in other countries. And to make to take this leap to say, no, actually you have agency and you can decide when you're suffering is too great. It is a pretty big philosophical leap to get to that point. I totally agree with that. That said, and you also have to be very brave to make the decision. Right. You have to be pretty darn brave to pick the date that you're going to die. However, you know, lots of hospice patients die at inopportune or unexpected times that can be pretty traumatic for the family. And contrast that with someone who invites who they want. And it's, it's kind of a beautiful scene. They might have music playing. They might have a few prayers and the person themselves gets to say goodbye to everyone in their family with their mentation intact. You know, I love you. Thank you. Goodbye. Everyone says goodbye to them. They drink this medicine and they fall asleep. I think that the research is going to show that it's a lot less traumatic for families because they are expecting it. And I don't mean to say it's not a sad day. It's a very sad day, right? No one wants to lose the person they love, but people say to me all the time, it was so peaceful. I could just tell their suffering is gone now. And I'd love to be able to say goodbye to them at that moment. So it really has to be thought of in a whole different way. I think it's, I mean, I have to say for me, I entered emergency medicine in the 1980s when it was kind of a new frontier, right? Emergency medicine. And now I feel like I'm on the cusp of a new frontier in medicine, which is medical aid in dying. And just to say to David, my patients, I don't have a 30% rate that people don't take the medicine. My rates, like 95% of people take the medicine. And the few that don't are usually because they die before they have the opportunity to get to the 15 days. And one other thing, I don't ever recommend to my patients that they should get the medicine and just keep it at home. I think that's a safety thing. And I think, again, most of us in the aid and dying community agree. I write the prescription, it's at the pharmacy and I tell them where it is. But then I say, please don't fill this until you're within a few days of wanting to use it. Safety, again, who wants that stuff floating around, right? So there's a lot of really interesting facets to it. And it's certainly an evolving field. And I do want to say for anyone who even has questions, even if you're not going to be a prescriber, ACA made a great resource, it really is. So. Dr. Henning, I see you have your hand up. Yeah. Thank you for this helpful discussion. Kevin Henning, I live in Washington state where medical aid in dying is legal. And I personally favor, you know, morally, personally, I favor the option for patients. But and I think we've, I wanted to share how I was thinking while you were talking, Dr. Plummer. So I want to, you know, even in the context of someone who lives in a state where it's legal, who favors the option for it, when you were describing the process of providing the prescription, being at the bedside, I felt myself getting anxious, just listening to you describe how you are at the bedside. And so I thought I would share that perhaps there were others on the call who, who felt anxious as well. And so I just think it, it, it bears mentioning how emotionally fraught this is, even for people who think it should be, should be available. And, and I think we're doing that by talking about it. So thank you. I thank for letting me share this bizarre, you know, almost unexpected little sense of anxiety I had just while you spoke about, about what that would be like. I mean, I've been in the ER doc, I've done much harder things than this. However, you know, like approaching an intubation, you always feel a little anxiety. I am anxious every time I go to a death because I want so much for it to go smoothly. I don't want there to be any wild cards, right? I don't want the person to unexpectedly, whatever, vomit or for the, you know, amp to show up from another state and make a big fuss and upset everybody. Like I'm always a little bit anxious to make sure it should go smoothly. I think it's like a natural reaction. So I guess I want to ask the people who are here, if we did another talk for this group, would it be helpful to go over the basics? Or do you think that we can skip the basics and just get into some of the higher level questions? That's one of the big questions we wanted to ask from this Q&A session. I guess I'll have you raise your hand again. Do you think it's, is it worth going over the basics and differences between the laws in different states? I don't know. Maybe you can put it in the chat. I don't know how to even ask. I thought you covered the basics pretty well. All right. Was that worthwhile for this group? Yes. But this is only what seven people, 12 people. If you did a larger scale talk, is it worth it to actually go over the basics of how the law works? That's my question. In other words, is this new information to people? For Dr. Henning, I know you have a big, pretty big team. Do you think your physicians would find it valuable? Or would they like more detailed information? Well, the company I work for actually multi-state hospice organization, and it's not legal in any of our states. So even though I live in Washington state, we don't have any, we don't have hospice here. So for my docs, it's not legal anyway, but not to say they shouldn't learn about it. So I think the basics for them would be helpful. Yes. Okay. And you're going to have people who are going to ask about going to other states now. Yeah. Because that's starting to be, you know, more publicized. So no, I guess the biggest thing is if somebody asked in a non-made state, what if I went to Oregon or Vermont, how long would it take? Like, I don't want them to be told, Oh, six months at least. Right. Like I want to have some general sense of how long it would take. And conversely, they shouldn't think they can go there and get it in two days. I have people who call me up and say, I want to take this tomorrow. Like you are out of luck. Right. So, but I think for most of us who are doing this full time or devoting a lot of time to it, we're all really, really careful. We want to follow the rules. You know, there are people you have to say no to, which is hard, but you know, we're all really conscious that because it's a new thing, we do have to adhere really clearly to the guidelines. If there's some people who are not going to be able to take the medicine and to try to minimize things going wrong, to do it carefully and thoughtfully. I'd be curious if we, I think if we're trying to state that it's going to be a better death, I think one of the things that clouds is if there's just not proper reporting, including, like I say, if we, if we're, if, if there's not some way of noting that on the death certificate or some type of process in the state, how do we ever, how do we ever prove that it's a better death? You know, because I think that's a key part is like, like you say, there's not, there's nowhere in the medical system where we capture that this was part of the dying process, which would be, which would be true of, you know, like my palliative sedation. You have to have a specific study on it, you know, to be able to say it, but that's the thing is, yeah, is there some way of capturing so we can actually start getting results that actually, cause I, I go back to then if, if like, again, when, and what would be complicating the study is when you say it's a very nice process, you're there. And I, and I wonder if I gave the same, if I made sure, so I was going to say every death like this had to be attended by a clinician. I'd want it compared with a death attended by clinicians for other causes and see what the, see what that does as far as, as far as that, that's kind of like why our hospice goes to daily visits and a much more, you know, structured approach and watch on a patient when they're in the active dying phase. So we try to give the proper amount of support and help to the families during that time. So it'll be, that'll be interesting. Data's going to, data's going to be one of the few things that could soften some hearts out there like mine. I mean, I'm, if someone asked me about metabolic and dying, I'm going to be telling them, you know, that we don't have that in this state. And I'm actually not going to probably spend a lot of time trying to help them with that. I'm going to go back to the question that I was trying to do all along. And I feel it's serviced me well, which is asking them, Hey, tell me more about, that's important what you just asked. Tell me more about why you asked that. I ask in an open nonjudgmental way to learn more about the needs of that patient. And it doesn't cross my mind to start helping coaching them how to get to another state. It starts talking about how do I take care of the needs of this patient here. And before I would start even thinking about potentially referring to another state, I'm going to have to have strong data that tells me that's a better dying process than what I'm trying to give them in their, in their natural dying process. So a couple of things. One is if I ask people why they're interested in doing aid in dying, the answer is, and I'm going to paraphrase this. Here I am stuck with this disease. That's taken away all my control, whatever it is, ALS cancer and stage heart disease. This is one really important way that I can have control at least over what my end will look like. Who will be there to know I'm not going to be suffering to know I'm not going to be short of breath and gasping or doing something embarrassing in front of my family. Like that's what they say, getting control back. As far as data, every state collects data. They're not, they're not ever going to disclose names of patients, but they like whenever I see a patient for aid in dying, I have to submit like 12 pages. Okay. To the New Jersey department of health, which is another deterrent to doctors doing this. It's a lot of paperwork. They don't ask me about the quality of dying though. What they want to know is that there's no medicine that's out there. That's not matched up right with the patient who either took it or that it's been properly disposed of, but they want to know demographics who's using it. ACA made has a database. Again, they're not asking about quality of dying, but they're as they're collecting data about times, but university of Colorado has several studies going. And I know this because they're always trying to recruit. Some of them are where patients who are considering aid of dying, and they do several interviews asking, why would you choose this option? That will be very illuminating. And I think they're also doing some studies about how was it for the families? And again, I've been a hospice doctor. I've worked in the inpatient unit before I knew what aid of dying was. I was president, you know, for days to weeks with people who were slowly dying and spent a lot of times with family. It is a different quality of dying. And there is really something about being able to choose the time that's really empowering to people. It's quite different. So yeah, it takes a little while to kind of, you know, get your head around what it is, and it's not going to be right for everyone, for sure. There are certainly people who have, you know, religious objections, although I've taken care of people from every religion, which is really interesting too. Even people who initially think they're going to be opposed to it, their fear of suffering or their desire for control often, you know, takes precedence over their fear. So it's certainly something that does require a lot of, it's going to require data collection, I agree. And I guess I can just give you anecdotal types of stories at this point. So. Any other questions that any of you might have? Well, thank you guys so much for joining us for this chat and discussion. And Dr. Plummer, thank you for presenting the information from New Jersey and the work that you're doing. Thank you for having me. And if anyone has individual questions, you can find me. Yes. And thanks for being a member of our community. Oh, thank you. All right. Bye, everyone. Thanks, Dr. Plummer. Thanks, Dr. Wenzel. Bye, everyone.

medical aid in dying

MAID

end-of-life option

patients' requirements

attending doctors

consulting doctors

self-administration of medication

emotional aspects

logistical aspects