Commentary

Leffler: What Vermont’s new end of life choice law means for Fletcher Allen

Editor’s note: This piece is by Stephen M. Leffler, M.D., the chief medical officer at Fletcher Allen Health Care and former medical director of the Emergency Department, who has been a practicing physician for 20 years. It was first published on the Fletcher Allen blog on June 5, 2013.

Vermont became the fourth state in the nation to make it legal for a patient with a terminal illness to obtain a prescription with the intent to hasten their death.

Unlike most new laws, where there’s usually a period of several months before they go into effect, this one went into effect last week, immediately after being signed by the governor.

This new law raises complex emotional and ethical issues for patients and providers. While the intent of the law is clear, the rules and regulations for how it will be carried out still must be determined.

Should we make the interim ban permanent? Should we educate our providers on the best methods to carry this out? Should we credential providers to perform this service? Should the medical staff oversee and review cases?

Our Legislature allowed health care facilities to be excluded from the legislation for patients who are residents of the facility and intend to take the medication on site. Fletcher Allen has chosen to enact the facility exemption on an interim basis. This will give us the opportunity to develop a thoughtful, compassionate policy that will respect our patients and providers.

Our medical staff has already started a dialogue on the new law. Issues that face us include: Should we make the interim ban permanent? Should we educate our providers on the best methods to carry this out? Should we credential providers to perform this service? Should the medical staff oversee and review cases? Our Ethics Committee has met twice and is developing a plan to allow and encourage all opinions to be heard.

Our institution also has a number of complex decisions to make. Will our pharmacy carry and supply the medication? Will we regulate what medication to use? What if a patient brings the medication from home and wishes to self-administer it here? If a patient is requesting a prescription with the intention to hasten their death and our facility does not participate, would we transfer the patient to another facility?

Fletcher Allen’s clinical and administrative leadership are committed to thoroughly reviewing the new law and, through an inclusive process, answering all of these questions to the best of our ability. The answers will help guide our decisions, including whether to permanently exercise the health care facility exception.

Most importantly, it is imperative for us to approach the new law in a way that continues to focus on the patient being the center of our care.

Fletcher Allen currently has comprehensive programs for patients at the end of life. We have outstanding palliative care and hospice care providers and services, delivered here on a daily basis. While giving patients another choice at the end of their lives, this new law does not replace these crucial services – and as happened in Oregon when it passed similar legislation almost 15 years ago, hopefully its passage will lead to a better understanding and expanded use of both palliative care and hospice care.

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  • Brian Otley

    While VT’s new end-of-life legislation is brand new and Vermonters are still wrapping their heads around its implications, I have to say this is a disappointing response from Fletcher Allen leadership. Of course there are issues to be worked out as a result of this legislation – just as there are with most new legislation being implemented in the real world. Organizations that lead change drive quickly to create clarity and effective working mechanisms to implement such legislation. Bureaucratic organizations fixate on the gray area of legislation to create delays and waste – “the rules and regulations for how it will be carried out still must be determined.” I may be misinterpreting Dr. Leffler’s tone here, but it reads to me like an early warning that there will be a long delay and lots of debate before Fletcher Allen implements its procedures related to VT’s end-of-life law. At a time when healthcare cost increases dominate so much of the national debate we need VT’s flagship health delivery system to lead change in this matter, not debate and delay and create unnecessary cost.

  • Brenda Pepin

    I’m not disappointed in Fletcher Allen’s response at all! In fact, I am relieved. This bill was hastily pasted together in the final hours of the legislative session by the super majority. I listened to Dr. Diana Barnard’s testimony before two legislative committees and was appalled when she stated that “Life is a terminal illness.” Wow. Since she works in the Palliative Care section of Fletcher Allen, the delay in implementation is good news to me.