MAID, which stands for Medical Aid in Dying, is a legal option in New Mexico. The University of New Mexico medical school recently held the first state level conference to help educate clinicians on this option. No other state that has MAID laws has had its own conference on medical aid in dying. In many ways, New Mexico is exceptional in its implementation of MAID. Here are some notes from that conference.
An Overview of MAID
An Overview of MAIDLonny Shavelson, MD, founder of the American Clinicians Academy on Medical Aid in Dying, provided an overview of the history of MAID.
Medical aid in dying started in Oregon in 1997, and it was the only U.S. state that allowed it until 2009, when Washington and Montana approved it. Vermont approved MAID in 2013. California and Colorado approved it in 2016, followed by Washington DC in 2017, Hawaii in 2018, and Maine and New Jersey in 2019. As the use of MAID spread, each state was doing their own thing in isolation.
On February 15, 2020, Dr. Shavelson and others started the American Clinicians Academy on Medical Aid in Dying to help coordinate the implementation of this growing medical movement. New Mexico approved their MAID law on June 17, 2021. The legislation was created with a foundation of knowledge from the progress made with previous states laws and practices.
Definition of medical aid in dying: Medical aid in dying refers to the legal practice where a clinician cares for a terminally ill patient who considers and potentially follows through with hastening their imminent death through the use of medications prescribed for that purpose. Earlier descriptions of medical aid in dying have characterized it as writing a prescription, at the patient’s request, for a lethal medication. Clinical best practices have since discouraged this limited focus and now emphasize the evaluation and care of terminally ill patients considering the option of a physician-assisted death
This care includes discussion of all options, the patient’s likely dying process (which differs widely depending on the illness), coordination of care in hospice care with aid in dying as the patient’s condition changes. It’s especially important for the clinician to follow the conditions of the patient’s GI (gastrointestinal) tract, because that is usually how the patient ingests the medication. Opiate tolerance can slow down the amount of time for the patient to die after ingesting the medication.
Dr. Shavelson shared a story of a patient who watched her father die a horrible death from cancer 50 years ago. She had skin cancer that had spread to her liver, and she was afraid of meeting the same fate. She asked for medical aid in dying, but now there are palliative and hospice care that didn’t exist when her father died. She used palliative care and hospice and lived for months. When she was about a week from dying, she requested MAID to avoid a painful death.
Dr. Shavelson said that New Mexico Exceptionalism starts with the state’s law. The legislation was built upon good practice and correcting errors, improving upon the other states’ experiences. There was a big problem with a 15 day waiting period and multiple requests. People were painfully dying before they could get the medication. In New Mexico, it takes one verbal request and a 48 hour waiting period, which can be waived as circumstances dictate. Enrollment in hospice confirms a second opinion of a medical professional. Nurse Practitioners and Physician Assistants can prescribe. Self administration does not prohibit assistance (as with physical disabilities of ALS and Parkinson’s disease patients).
End of Life Options New Mexico is a nonprofit organization that has been incredibly helpful in educating the public. In a data review of states doing MAID care, including seven major states, New Mexico has the lowest mean time to death of 75 minutes. Other states are longer – 115 minutes in Oregon and Washington. It could be the attention paid to gut function. There’s a high rate of attendance by a clinician at the death, more than 90% of teams physician, PA, hospice nurse, death doula, family, and pets.
The Basics of MAID in New Mexico
Presented by Jacqueline O’Neill, MD, University of New Mexico Hospital (UNMH), Lead MAID Program Lead Physician
There are currently 16 hospices in New Mexico that provide MAID and four independent providers, including UNMH. There are a total of 38 hospices in New Mexico. MAID qualification criteria in New Mexico are:
- Patient has a terminal illness with a 6 month prognosis.
- Patient is a New Mexico resident.
- Patient is over the age of 18.
- Has decision making capacity.
- Able to self administer the medication.
Evaluators can be a physician and hospice, two doctors, or a doctor and a Nurse Practitioner or Physician Assistant. Not all patients on hospice have a MAID qualifying prognosis. Presence at bedside during the ingestion of MAID provides legal immunity to providers. The diagnoses of Coronary Artery Disease and Protein Calorie Malnutrition needs further clarification. Residency is defined as residing in a particular place for the indefinite future.
Self administration problem: A patient with ALS may likely lose the ability to swallow or push a syringe plunger. In New Mexico, the law does not specifically require independence or prohibit assistance, as long as patient makes an “affirmative, conscious voluntary action to take the medication.”
Providers need to work with family members to communicate about the patient’s needs and concerns. The patient needs to fill out a verified consent form that is signed by two witnesses. Only one witness can be a family member, and the medical provider cannot be a witness. The prescription can be obtained in 48 hours or sooner. The cost of the medication ranges from $250 to $550. It is covered by Medicaid, but not Medicare.
Provider etiquette on day of aid in dying:
- Provide reassurance about process, expectations for ingestion and dying process.
- Prepare for possible burning sensations.
- Educate the family/loved ones about coma and death.
For patients who are not on hospice when they use MAID, the Office of the Medical Investigator (OMI) needs to be informed about the death and the primary care doctor should make the death pronouncement.
Medication Information
Lonny Shavelson, MD, traced the development of the current combination of medications used in MAID. Prepared by a compounding pharmacy, the different elements have evolved over the course of time as more states started to allow medical aid in dying.
In the current iteration of the medication, there are several elements. The morphine in the life-ending medication is 15,000 mg and the usual dose of morphine for hospice patients is 200 mg. Very bitter! And it burns going down. It is a good practice to offer the patient sorbet or popsicles pre-ingestion. The cold of the icy treat reduces the bitterness. He cautioned against using ice cream, as the fat is problematic for ingestion. He also recommends giving more sorbet post-ingestion of the medication to minimize the burning sensation. Imagine seeing a loving person taking care of the patient as they drift off to sleep.
Two ounces of the liquid medication versus four ounces was found to be absorbed faster and safely. While it’s twice the density, it goes down quicker with less bitterness and burning, and provided improvements for shortening the time to death.
The most common reason for a prolonged death is that the gut isn’t working properly and the medication doesn’t get absorbed well. The patient may develop gastroparesis, when the stomach delays emptying, and there may be nausea and vomiting. Constipation can also negatively impact prolonged dying. High levels of opioid tolerance can also impact the length of time to death, but the dose can be increased.
Other topics presented at this New Mexico Clinicians Conference on Medical Aid In Dying included “Responding to a Request for MAID,” “Capacity and Judgment in Aid in Dying,” “Understanding Suicidality and Depression in MAID” and a panel discussion with survivors, people whose loved ones used MAID. For more information about MAID, visit this online resource: www.acamaid.org.
Author: Gail Rubin, Certified Thanatologist and The Doyenne of Death®, attended the conference. She is also the coordinator of the Before I Die New Mexico Festival.