In the shadows of compassion: The aid in dying debate in California
Since 2016, nearly 4,000 terminally ill patients have opted for physician-assisted death.
Before Jaime Feliu pressed the plunger on the syringe, he said goodbye to his family. He told his children that he was proud of them and told his wife, Patricia that he loved her. They told him the same.
On October 14, 2023, Feliu pressed the plunger and within five minutes he was asleep. In an hour, he was dead.
Feliu was one of hundreds of terminally ill patients in California this year who chose to end their lives through the state's End of Life Option Act.
"We loved him," said Patricia Feliu about her husband's death. "He was a vital part of our everyday life. It comes in waves, sometimes the waves of sadness are small and you can step over them and then sometimes they come and knock you over. We are sad but Jaime's death was very peaceful. And so that is what keeps us from, I think, completely falling apart."
For Jaime Feliu, it was an end to the tortuous pain that he endured from esophageal cancer that ate away at his body and eventually made its way to his brain.
For his family, it was knowing that Feliu was at peace, that he exited on his terms and not after being ravaged by pain and discomfort.
For Dr. Bob Uslander, the Solana Beach physician who prescribed Jaime Feliu the deadly medication, it is another example of the benefits of California's End of Life Option Act.
Since 2016 when medical-aid-in-dying was legalized in California, Uslander has ushered nearly 600 terminally ill patients to their end. Uslander is one of few physicians who specialize in aid-in-dying and end-of-life care.
And despite the law being in its seventh year, the law is not widely known, and many patients and families, as was the case with the Feliu's, were not aware of it or the regulations surrounding it. Meanwhile, the End-of-Life Option Act continues to be surrounded by controversy, chief among them are other physicians who say the act and the doctors who prescribe it, such as Uslander, are violating the basic tenets of medicine.
The End of Life Option Act
Since June 2016, when then-Governor Jerry Brown signed the End of Life Act into law, through January 2023, doctors have prescribed 5,168 lethal doses to adults over the age of 18 who had terminal illnesses and were given less than six months to live. During that time 3,349 people took the aid in dying drugs and died.
The California Department of Public Health data shows during 2022 the median age of the 853 people who were confirmed to have died from the prescriptions was 78 years old. Of those, only 8 percent were under the age of 60 while 17 percent were over the age of 90.
In terms of race, the data from 2022 shows that 89 percent of those who died were white, more than half were males, and two-thirds suffered from cancer.
In 2022, according to the Department of Health, 341 physicians submitted prescriptions under the medical-aid-in-dying law.
In order to qualify for an end-of-life prescription, patients must meet a number of guidelines. First, they need to be over 18 years of age. They must have a terminal illness with a life expectancy of less than 6 months. They must request the aid-in-dying medication and follow up with a second request no sooner than 48 hours later. They must also be of sound enough mind and have enough physical ability to administer the medication to themselves.
The vast majority of the prescriptions, 89 percent, were a medical cocktail comprised of a Cardiotronic, a drug that increases the heart's output, an opioid, and a sedative.
Patients who are prescribed aid-in-dying drugs must ingest them on their own, without the aid of another person or a doctor.
The patients, as was the case with 69-year-old Jaime Feliu, fall asleep a few minutes after ingesting the dose. Depending on the person, death comes anywhere from 15 minutes later up to several hours, with the patient asleep the entire time.
Empowered Endings A private practice specializing in end-of-life
Former emergency room doctor Bob Uslander switched his focus to palliative and end-of-life care in 2013.
"In 2013, I was sitting on a bluff in La Jolla and I was contemplating my life and I had this epiphany. I actually heard the words, 'You're here to help people die,'" said Uslander. "From that point forward, it was clear that I was called to support patients and families in a more empowered dignified, gentle end of life."
Months after finally opening his private practice in January 2013, then-Governor Brown signed the End-of-Life Act into law.
Uslander says patients, families, and other doctors immediately began calling him.
"Even before the law went into effect people started calling my office because they knew that this was going to be an option for them," said Uslander. "They couldn't find any other doctors to help them. Because I have my own practice and because I really believe in autonomy and freedom of choice, I was open to helping people."
Uslander estimates that he through his clinic, Empowered Endings, has written approximately 600 prescriptions, more than a tenth of all prescriptions written in the state since June 2016.
Uslander says his practice is more than just writing prescriptions, it's making patients and families make a devastatingly difficult time more manageable and peaceful by offering "death doulas" to help as well as counselors for the families.
As for questions about the ethics of running a private practice that makes profits off of patients' deaths, Uslander says that is far from the case.
"Everyone in healthcare is profiting off of people. If I could, I would do this for free. But I have a team of people that I'm supporting and a team of employees who are counting on me to provide for them. I make less than most physicians at this point. And we're also supporting people through my clinic's foundation while providing education. So does it weigh on me that I'm getting paid for providing superior medical care now? It doesn't," said Uslander.
As for critics of the law and Uslander's work who say the doctor is violating a basic tenet of medicine to not do harm, Uslander scoffs at the position.
"The idea that forcing a person to endure suffering far beyond what they're willing to is what is harmful. The harm that comes from forcing a person to experience the final indignities and ravages of terminal cancer, end-stage heart disease, or ALS when there's an option for them is more harmful," said Uslander. "Again, these people are dying. I don't believe that we're doing any harm by giving them the option to die more quickly if that's what they choose. And the planning is so critical, that one of the things that we really focused on is helping people have the conversation so that they can tell everyone what they want or don't want."
The critics
Dr. Leslee Cochrane has specialized in palliative care and hospice since 2004. He has also been a staunch critic of California's End of Life Option Act.
Cochrane's objections are two-fold, the first is the breach of his faith, and the second is that the law violates the Hippocratic Oath that is at the center of the medical profession.
"For thousands of years, physicians have treated patients. It's never been considered to be medically necessary to kill a patient in order to treat or manage their symptoms," said Cochrane. "There are incredible options available for patients and assurances that their pain and symptoms can be brought under control. It's never medically necessary to kill a patient in order to achieve that objective."
In 2021, Cochrane and the Christian Medical and Dental Associations sued the State of California after lawmakers amended the End of Life Option Act in an effort to compel doctors to participate in medical aid in dying. The amended law also lowered the waiting period that patients had before making their second request for the prescription from 15 days to two days.
In May 2023, Cochrane and the association were victorious on one front. It barred the state from sanctioning doctors or healthcare professionals who refused to participate in the End of Life Option Act. The state paid Cochrane and his attorneys $300,000 to settle the case. The settlement, however, did not change the shorter wait period that patients had to make their second and final request.
"Physician-assisted suicide raises significant moral and ethical questions, Cochrane said. "We've been struggling with these questions for thousands of years. We go back to the Hippocratic Oath, which was written in the times of ancient Greece. I took that oath and I gave a solemn vow that I would never harm a patient."
Cochrane said the End of Life Option Act sets the state up to head down a slippery slope.
"The same rationale that justifies physician-assisted suicide will justify euthanasia," said Cochrane. "When I graduated from medical school, I never imagined a world in which I would have to sue the government to prevent it from forcing me to help patients kill themselves. So when we're talking about physician-assisted suicide, I think we have to look at the unintended consequences. This idea of a compassionate death is very important. But that can be achieved without physician-assisted suicide and it has for hundreds of years. We do that on a daily basis with hospice."
'Death With Dignity'
For Uslander, however, the focus should remain on the patients and their families. The doctor says he plans to expand his practice and establish a foundation in order to help those without the means to pay.
"It's the patient's choice to shorten the dying process and reduce their suffering and pain. The patients are almost always very resolute and comfortable when making that decision and in turn is reassuring for the families. The vast majority of the time, the atmosphere is light. There's a sense of them reaching the finish line. Most of my patients are happy. They're joking, and they're experiencing this really deep sense of love and connection with their families."
That connection, said Patricia Feliu, the widow who watched her husband Jaime press the plunger less than two weeks prior to speaking to CBS 8, is what keeps her and her family from getting knocked over by the waves of emotions from losing her husband and her kids losing their father.
"We're sad," said Feliu. "But there is something to 'death with dignity,' the experience was positive, it was very peaceful. And so that is what keeps us from completely falling apart sometimes. We are able to focus on all the positive things that Jaime did and the life that he led. It was a life well lived."