Erin N. Deja, PharmD Candidate

By the time of his death in 2011, Dr. Jack Kevorkian was said to have assisted in the suicides of at least 130 patients. In part because of his advocacy, physician-assisted suicide became a heated topic of discussion in the 1990s.

Five states—Oregon, Washington, Vermont, Colorado, and California&mdash;and the District of Columbia now have Death With Dignity acts that allow adults with a prognosis of no more than 6 months to live to choose to end their lives. Montana allows an “end-of-life option” via a ruling of the state’s supreme court in 2009.

 The intent of such laws is to help terminally ill patients avoid undue pain and suffering and allow them more autonomy in decisions concerning their end-of-life care. Participating individuals must be mentally competent, able to voluntarily request and obtain the necessary prescription, and self-administer the medication.

 Most participants are younger than 65, have received a diagnosis of terminal cancer, and are in hospice care.

 All health care providers involved in the process are legally protected from charges of assisted suicide, homicide, and elder abuse.

Death with dignity is a controversial issue. Thirty-seven states have laws expressly prohibiting physician-assisted suicide,

 and physician opponents say that actively participating in the death of a patient violates the Hippocratic Oath, which instructs doctors to “do no harm.” Health care systems with religious affiliations also oppose death with dignity, claiming that death is a “sacred part of life’s journey” that should neither be hastened nor delayed.

 Furthermore, there is concern that such laws open the door to potential abuse.

 The determination of a patient’s prognosis can be arbitrary, and physicians are not held accountable for the life-ending drugs that they prescribe. This lack of accountability may lead to patients being pressured by physicians or family members into committing suicide or using physician-assisted suicide to avoid exorbitant medical bills.

In response, because an individual’s decision to die with dignity is viewed as strictly voluntary, health care providers, hospitals, and physician groups may opt out without the risk of penalty.

Advocates of death with dignity argue that the practice is uncommon; a physician may encounter the situation only once or twice in a career. Further, since the passage of the Oregon law in 1997, fewer than 2000 prescriptions for lethal drugs have been written in Oregon, and just 65% have been used. This is a pattern that is consistent year after year (FIGURE 1).

 Moreover, choosing to die is not an instantaneous decision. For example, Oregon law requires patients to make 2 oral requests to their physician at least 15 days apart, followed by a written request signed in the presence of 2 witnesses. The attending physician must then confirm the patient’s diagnosis and prognosis with a consulting physician. If either provider believes that the patient’s judgment is impaired by a psychiatric or psychological disorder, then a referral for a psychological evaluation must be made. If all requirements are met, then the physician must inform the patient of all reasonable alternatives to death with dignity. If the patient confirms their decision, the medication must be dispensed directly to the patient by the physician or via a written prescription delivered to a pharmacist either by the physician or through the mail. The patient may rescind the request at any time.

 Such conditions ensure that the physician’s and the patient’s judgments are neither hastened nor coerced.

Prescriptions for the high doses of oral barbiturates that are typically used in physician-assisted suicide may end up in the hands of a community pharmacist.

 This raises important considerations for the pharmacist, including patient-counseling issues, legal requirements, moral and ethical concerns, and consequences for refusing to dispense the medication. The American Society of Health-System Pharmacists released a statement in 1999 regarding pharmacists’ participation in death with dignity. The statement indicates that it is the duty of a pharmacist to provide patient-specific care and to respect the autonomy of the patient but that it also is the right of the pharmacist to choose not to participate in “morally, religiously, or ethically troubling therapies.”

End-of-life care presents a great opportunity for pharmacists to exercise their expertise. Physicians and pharmacists must contemplate the implications of death with dignity laws on their personal beliefs and future practice to provide empathy, understanding, and the best possible care to their patients.

Source: Oregon Health Authority Public Health Division, Center for Health Statistics. February 2017.

Erin N. Deja is a fourth-year PharmD student at the University of Kentucky College of Pharmacy.

Joseph L. Fink III is a professor of pharmacy law and policy and the Kentucky Pharmacists Association Endowed Professor of Leadership at the University of Kentucky College of Pharmacy, Lexington.

Davey M. Kevorkian speaks after his release from prison. 

website. nytimes.com/2007/06/04/us/04kevorkian.html. Published June 4, 2007. Accessed June 6, 2017.

LeBlanc J, Struve A, Mendoza L, Levy M. Difficult choices for healthcare providers as California legalizes assisted suicide. Lexology website. lexology.com/library/detail.aspx?g=ad4f41bd-ce90-48da-bce2-345bc3fcfcfa. Published October 10, 2016. Accessed June 6, 2017.

Oregon Death with Dignity Act. Ore Stat §127.800.

Oregon Health Authority, Public Health Division, Center for Health Statistics. Oregon Death with Dignity Act. Data summary 2016. Oregon state website. public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year19.pdf. Published February 10, 2017. Accessed June 6, 2017.

Gray K. Bill legalizing assisted suicide gets new life in Lansing. 

website. freep.com/story/news/politics/2016/08/13/bill-legalizing-assisted-suicide-gets-new-life-lansing/88537468. Published August 13, 2016. Accessed June 6, 2017.

Judge refuses to suspend California’s assisted death law. Modern Healthcare website. modernhealthcare.com/article/20160827/NEWS/160829934. Published August 27, 2016. Accessed June 6, 2017.

ASHP statement on pharmacist’s decision-making on assisted suicide. 

Articles

Five states&mdash;Oregon, Washington, Vermont, Colorado, and California&mdash;and the District of Columbia now have Death With Dignity acts.

Death With Dignity: A Right or a Crime?

Ease of access to birth control has always been an issue for women everywhere. Although men are able to purchase condoms over the counter, women are required to make annual appointments with physicians in order to receive a prescription for contraceptives. This can present significant barriers to receiving appropriate therapy, whether related to the cost of an appointment or the need to take time from work to accommodate a physician’s schedule. These and other barriers may force many women to forego contraceptive therapy altogether, likely contributing to nearly 50% of pregnancies being unintended in the United States each year.

Several states, including Oregon, California, Washington, and, most recently, New Jersey, have begun to address these issues by enlisting the services and expertise of pharmacists.

 These states have enacted legislation that allows pharmacists to prescribe and dispense self-administered hormonal birth control, including oral tablets and transdermal patches, without a physician’s prescription. Pharmacists who wish to participate in these practices must first complete the necessary training seminars mandated by their state. Although the laws vary slightly in regard to required patient age or products authorized to prescribe, it is generally universal that pharmacists must obtain a patient’s relevant medical history, pregnancy status, and medication history, as well as perform blood pressure screening, before authorizing a prescription. This is achieved with a 1-page self-screening questionnaire, similar to those used for immunizations.

Based on the results of these screenings, pharmacists can use a standard procedures algorithm (Figure) to evaluate the patient and make prescribing decisions.

 If, for some reason, the pharmacist declines to prescribe a contraceptive (eg, blood pressure exceeds 140/90 mm Hg), the patient may be referred to a physician for further evaluation. If a prescription is indicated and a product dispensed, the pharmacist must provide a summary form of the encounter, detailing which medication was selected and inquiring if the patient has any questions, allowing further counseling if necessary.

The response to the enactment of pharmacist prescribing laws has been dichotomous. Some physicians express concern that, without requiring women to have an annual checkup to obtain birth control, many will skip necessary testing. However, for women aged 21 to 65 years, a Pap test is recommended only once every 3 years or every 5 years, if co-tested for human papillomavirus at the same visit. Accordingly, pharmacists cannot write a prescription for a woman who is unable to provide evidence that she has visited a women’s health provider within 3 years of the pharmacist’s initial prescription for a contraceptive.

 While removing an unnecessary barrier to annual prescriptions, this caveat ensures that women will still receive the recommended screenings.

Pharmacists also express apprehension regarding the ability of community pharmacists to add contraceptive prescribing to their already long list of duties in a fast-paced work environment. Additionally, in states where pharmacists have not been granted provider status, there is concern that pharmacists will not be sufficiently reimbursed for their time and effort in evaluating and counseling patients. California law allows up to a $10 fee per prescription, but it is hoped that in the future, pharmacists will be able to bill insurance for services provided, just as a physician would.

On the other hand, the potential benefits of pharmacists prescribing contraceptives are numerous. The pharmacist is the most accessible health care provider, offering convenient locations and extended hours of operation that physicians typically lack. Patients who cannot take the time for an appointment to obtain contraceptive therapy can visit a local pharmacy and receive a prescription. Further, it is estimated that within the next 10 years, there will be a 27% shortage of primary care providers in the United States; however, the number of available pharmacists continues to increase.

 The expansion of pharmacists’ prescribing authority could decrease the burden shouldered by physicians largely due to the increase of newly insured patients under the Affordable Care Act.

Finally, it has been consistently proved that pharmacist involvement in patient care improves outcomes, increases adherence, and decreases costs. A recent study in Washington state surveyed 214 women evaluated by 26 community pharmacists for use of hormonal contraceptives. Of the women who responded, 70% reported continual use of their prescribed contraceptive after 12 months and nearly every respondent “expressed willingness to continue to see pharmacist prescribers” for this and other services. These results demonstrate that pharmacists are capable of screening patients and selecting appropriate contraceptive products, and are accepted by patients as primary care providers.

Pharmacists have long been an underutilized resource in our health care system. With increased prescribing authority, they may be able to provide much-needed care to individuals otherwise unable to access it, improve patient adherence and related outcomes, and offer some relief to overwhelmed physicians. The prescribing of contraceptives is just the beginning of this movement and could be followed closely by the prescribing and monitoring of medications for chronic conditions such as diabetes or hypertension. It is up to pharmacists to embrace this responsibility in the interest of their patients and their profession.

Erin N. Deja, a native of Union, Kentucky, is a third-year PharmD student at the University of Kentucky College of Pharmacy. Joseph L. Fink III, BSPharm, JD, is professor of pharmacy law and policy and the Kentucky Pharmacists Association Professor of Leadership at the University of Kentucky College of Pharmacy, Lexington.

CDC. Unintended pregnancy prevention. CDC website. cdc.gov/reproductivehealth/unintendedpregnancy. Accessed September 26, 2016.

Livio SK. Lawmakers vote to let NJ pharmacists prescribe birth control. NJ.com website. nj.com/politics/index.ssf/2016/05/lawmakers_agree_pharmacists_should_be_allow_to_pre.html. Published May 2, 2016. Accessed September 26, 2016.

Vivian JC. Pharmacists prescribing birth control. 

 website. uspharmacist.com/article/pharmacists-prescribing-birth-control. Published February 17, 2016. Accessed September 26, 2016.

Oregon state. Standard procedures algorithm for Oregon RPh prescribing of contraceptives. Oregon Administrative Rules website. oregon.gov/pharmacy/Imports/ContraceptivePrescribing/ORStandardProceduresAlgorithmForRPHPrescribingOfHormonalContraceptives11_2015.pdf. Accessed September 26, 2016.

Fundin J, Dragic LL, Raouf M. Should pharmacists prescribe birth control? 

. drugtopics.modernmedicine.com/drug-topics/news/should-pharmacists-prescribe-birth-control?page=0,3. Published January 27, 2016. Accessed September 26, 2016.

Feder Ostrov B. California, Oregon to allow hormonal contraceptives without a doctor's prescription. Kaiser Health News website. khn.org/news/california-oregon-to-allow-hormonal-contraceptives-without-a-doctors-prescription. July 15, 2015. Accessed September 26, 2016.

Ease of access to birth control has always been an issue for women everywhere.