End of Life Option Act

What is the End of Life Option Act (EOLOA)?

The End of Life Option Act (PDF) is a California law that went into effect on June 9, 2016, and was updated on January 1, 2022. The law allows individuals who have a serious, life-limiting illness (with a prognosis of six months or less) to request prescription medications from their doctor to end their life. This practice is also known as medical aid in dying (MAID).

Participation in the act is voluntary for John Muir Health patients, doctors and staff.

Who is eligible to pursue EOLOA?

In order to qualify, a John Muir Health patient must meet the following criteria:

• Be at least 18 years old
• Have the capacity to make medical decisions
• Reside in the state of California
• Have a diagnosis of a serious, life-limiting illness with a prognosis of six months or less (as estimated by two doctors)
• Be able to self-administer aid-in-dying medications via mouth, rectum or feeding tube.

What are the steps of the EOLOA process?

1. If you think you might be interested in pursuing EOLOA, please talk to a doctor on your medical team as soon as possible, even if you're not certain. Many patients wait until they become very sick or are already enrolled in hospice to discuss the topic, and this can make it much more challenging to access an aid-in-dying prescription. Completing this process can take one to three weeks, so it's important to allow ample time for each step.
2. Your doctor can provide more information about the EOLOA process and talk with you about your eligibility. If your doctor doesn't participate in EOLOA, your request will be documented and you'll be referred to a participating provider.
3. Once you have identified a doctor who is willing to prescribe EOLOA medications for you (often called your attending or prescribing physician), you need to make two verbal requests for these medications from your doctor. These requests need to occur directly from you to your doctor. Part of the EOLOA law requires that your physician speak with you alone for a few minutes.  Your doctor will let you know when it is time to do this. A waiting period of at least 48 hours must separate the requests.
4. In addition to meeting with your prescribing doctor, you'll be referred to a consulting doctor who will confirm your eligibility for and your wish to proceed with EOLOA.
5. Your prescribing doctor may choose to refer you for a single mental health evaluation to ensure that emotional distress isn't impairing your capacity to make a clear and thoughtful decision. This referral is based on your medical history, the doctor's clinical judgment and standard screening tools.You'll complete an aid-in-dying request form (PDF) from the Medical Board of California declaring your wish to pursue EOLOA, which needs to be signed by you and two witnesses, then sent to your doctor.
6. Once your eligibility has been confirmed and you have completed the oral requests, your prescribing doctor will work with you to prescribe the medications if and when it is appropriate and you choose to move forward. For safety reasons, your doctor will typically prescribe the medications within one to two weeks of your potential date of administration. We encourage ongoing close communication among you, your loved ones and your doctor as the date approaches.
7. We strongly recommend enrolling in hospice before ingesting your EOLOA medications to ensure you and your loved ones are well supported during this time. Your doctor can facilitate this referral when the time is right for you.

End of Life Option Act: Frequently Asked Questions

• If I ask my doctor for the EOLOA medications, do I have to take them?

No. You have the option to stop the EOLOA process at any point. If you have completed the request, you do not need to move forward with having the medications prescribed or ingesting them.

• If I ask my doctor for the EOLOA medications, does my doctor have to prescribe them?

No. A doctor's participation in EOLOA is voluntary. However, according to the law, if you are eligible for EOLOA, your doctor needs to document your request in the medical record and refer you to a provider who is willing to participate.

• Are these medications covered by my insurance?

Unfortunately, these medications are not covered by most insurance plans or hospice care, and they can be costly. Typically, the medications cost $700 for the prescription, plus delivery fees. If you have Medi-Cal, however, the cost may be covered.

• Do I need to see my doctors in person to complete these visits?

No. You may complete these visits in person or remotely via telehealth.

• If I'm out of state, can I pursue EOLOA in California?

No. You must be physically in the state of California to pursue the EOLOA process with your John Muir Health doctors.

• I'm not a John Muir Health patient. Can I come to John Muir Health just for EOLOA?

No. At this time, only established John Muir Health patients are eligible to pursue EOLOA with John Muir Health.

• I'm eligible for EOLOA and currently hospitalized. Can I get these medications while in the hospital?

No. Doctors providing inpatient care are unable to prescribe EOLOA medications. You need to be referred to a clinic after you leave the hospital to complete the EOLOA steps. However, while hospitalized, you may ask your inpatient team for additional information about the EOLOA process.

• Am I allowed to take these medications while I'm in the hospital at John Muir Health?

No. At present, use of EOLOA medications isn't allowed on John Muir Health property. If you live in a skilled nursing or assisted living facility, you should check your facility's policy on pursuing and taking EOLOA medications.

• Can I take these medications intravenously?

No. The medications come in a powdered form that's mixed with a liquid to make a solution. This solution can be swallowed, administered rectally via catheter (a thin, flexible tube) or administered through a feeding tube. You must be able to use one of these three routes without assistance. There is no legal option for ending your life with IV medications under either California state or federal law.

• I've enrolled in hospice. Can I still see my John Muir Health providers to go through the EOLOA process?

If you are already enrolled in hospice and decide to pursue EOLOA, you may be able to work with your John Muir Health doctors and your hospice team to complete the steps for accessing this resource. Please ask your doctor for guidance.

• How does the law affect my insurance, will or other contracts?

The law provides several protections for you:

o    You cannot be denied health insurance because of deciding to pursue EOLOA.

o    Your health insurance provider cannot tell you whether EOLOA medications are covered unless you ask directly. If you're concerned about insurance coverage or cost, talk to your doctor and your health insurance provider.

o    Your health insurance plan cannot refuse to cover treatment for your disease while it offers coverage for EOLOA medications.

o    A life insurance carrier cannot deny life insurance benefits because you have opted to pursue EOLOA.

o    A will, contract or other agreement cannot force you to receive EOLOA medications or prevent you from receiving them.

• I'm going through the EOLOA process, and I feel that I could use more support. Who can I turn to?

We encourage you to reach out to your doctor so your medical team can connect you to additional supportive resources. Please also see the resources listed at the bottom of this page.

        Preparation for taking EOLOA medications

Planning tips

• Once you complete the EOLOA process, it's important to seek ongoing guidance from your health care team as you approach the day of administration, especially if you're nearing the end of your life or experiencing confusion, difficulty swallowing, nausea, vomiting or a bowel obstruction.
• The EOLOA process can proceed only if you have: 
  • The capacity to make medical decisions. You must be able to clearly express your choice to pursue EOLOA and your understanding of alternatives to EOLOA and to acknowledge that ingestion of these medications is expected to result in death.
  • The ability to self-administer the medications via mouth, feeding tube or rectal tube. Please note that someone else can legally help you mix the medications prior to ingestion.
  • The ability to safely absorb the medications. A bowel obstruction or other intestinal issue may prevent you from absorbing these medications as intended. If this applies to you, it's crucial to talk with your doctor about a safe plan for taking the medications.

Important information for the week leading up to administration

• Notify your doctor, hospice team and loved ones (if you want them to know) that you are planning to ingest your medications and when you plan to do so.
• Arrange to have loved ones in your home on the day of administration. If some members of your “support team” don't know each other, consider having a meeting – ideally, prior to the day of ingestion – to introduce them and clarify each person's role. We also encourage you to ask your hospice team whether a volunteer or nurse can be present during this meeting.
• Consider identifying a “point person,” such as your main surrogate decision maker (who may be your emergency contact or your durable power of attorney), to be the main spokesperson with your medical team.
• Visualize the experience you want to have on the day you take the medications, and discuss this with your loved ones, if applicable. For example, consider whom you want to be present, as well as whether you want any special music, food or other experiences in the hours leading up to your self-administration.
• If taking the medications orally, practice swallowing one half-cup (4 ounces) of slightly thickened liquid in the days leading up to your ingestion. You may use a straw, if helpful.
• Ensure your bowels are moving regularly (at least every other day) leading up to your ingestion. If needed, talk to your doctor about ways to increase the frequency of your bowel movements.
• Continue all your usual medications unless your medical team advises you otherwise.
• Finalize plans for your remains by talking with your loved ones and your local mortuary. If you wish to have a specific ritual after your death, make this clear ahead of time. The mortuary doesn't need to be called immediately after death, but it does need to be selected ahead of time.

Important information for the day you take the medications

• We recommend eating and drinking lightly beginning the night before, so as to avoid significant nausea and ensure your body can fully absorb the medications.
• Instructions for mixing your medications: 
  • Choose a clean, safe and well-lit surface to mix your medications on. Ensure that pets and other people, especially children, stay clear of this area as the medications are prepared. These are dangerous substances.
  • Cover the surface with a clean paper towel. You may use medical gloves, if desired, but this is not required.
  • Have all supplies ready nearby, including the powdered medications, a liquid measuring cup and a liquid of your choice (this may be water, but apple juice or another beverage whose taste you like may be preferable due to the medications' bitter taste).
  • Pour 4 ounces (a half-cup) of your desired liquid into a measuring cup.
  • Before opening the medication bottle, gently tap the bottom so the powdered contents settle.
  • Open the medication bottle away from your face. Pour 2 ounces (a quarter-cup) of your desired liquid into the bottle, reseal it and shake vigorously.
  • Reopen the bottle and pour the remaining 2 ounces of fluid into the bottle. Shake vigorously.
  • Once the medication is mixed, it can be brought to your bedside for ingestion. Ensure that you are settled comfortably in a bed or chair prior to taking the solution.
  • After ingestion, your support person will need to thoroughly clean the medication bottle and the measuring cup. This person should seal the bottle in a plastic bag and place it directly in the garbage.
• Instructions for administering EOLOA medications: 
  • Take your anti-nausea medications one hour before ingesting the EOLOA medications.
  • One hour after taking the anti-nausea meds, self-administer your EOLOA medications. There is a two-minute window to complete the administration.
  • Note that these medications are bitter and can cause mild burning and coughing. This will resolve within a few minutes after ingestion. In the meantime, feel free to take sips of juice, lick a frozen ice pop or take small bites of sorbet (not ice cream, as it can interfere with medication absorption) to soothe these sensations.
  • These educational videos from the American Clinicians Academy on Medical Aid in Dying provide more information on enactment of EOLOA at the bedside and proper mixing of medications.

Support for loved ones during and after this process

• Common signs and symptoms of dying: 
  • People who take EOLOA medications typically fall into a deep sleep within 10 minutes of administration, followed by coma, respiratory depression, and death shortly thereafter. Typically, death occurs within two to five hours of ingestion. The dying experience can happen very quickly. It's important to prepare loved ones for this, as it can be different from other dying experiences.
  • While in a coma, the person will still be breathing. After taking EOLOA medications, people commonly exhibit symptoms of dying that don't cause them to suffer but can be startling for loved ones to witness. These include deep gasping breaths, gurgling sounds and changes in facial color to pale or blue.
  • If you have any concerns while your loved one is going through this, call your hospice team or doctor for guidance.
• Important steps after death: 
  • Loved ones should call the patient's hospice team and mortuary to notify them of death.
  • Mortuaries typically send someone within 30 to 90 minutes of receiving this call, unless you've made other requests or arrangements.
  • The hospice team can provide bereavement support for loved ones, as needed.