Table 2.

Domains of clinical practice: sub-themes and illustrative quotations

Clinical Communication and Counseling
Understand the request	“If someone says, ‘I want you to help me die, I want Act 39,’ the first question is, tell me more. And we deepen the conversation.” (Physician, 0101) “There is an obligation to do everything you can to try to keep them from feeling like they need to use that. You don’t just give them the gun without the gun education, you know…You just loaded the gun for them and you need to make sure that they understand what they’re doing, and that everything has been done to treat their distress.” (Physician, 0110)
Address untreated symptoms
Discuss alternatives
Explain the law
Talk with family members
Frame as last-resort option
Act 39 Protocol
Verify eligibility	“His primary doctor…was unsure about his timeline, couldn’t say for sure he had six months or less. But his neurologist and our hospice medical director who had been seeing him both said, ‘Absolutely he has a prognosis of six months or less, and to come on to hospice services in the first place, you have to have that prognosis.’ So, it was kind of interesting to see physicians butting heads.” (Nurse, 0135) “We had to work with him and find, you know, another physician in the community who was on board with it, and that was not an easy task, took a lot of education, effort, support to other providers.” (Nurse, 0131) “Turns out all he had to do was register to vote to say he was going to be, that he was legal resident. The law left open that established care and established residency, they left up to the discretion of the doctor. We didn’t have any guidelines for it and we just didn’t know.” (Nurse, 0119)
Complete paperwork
Identify and coordinate with pharmacy
Identify second physician
Consult legal and/or ethics service
Prescribing
Select medication and dosage	“The state website has the process. They don’t have the how to. And so that’s a little hard to do. I think in the end I contacted ((advocacy organization)) … I ended up getting a hold of a physician out in, uh, ((name of city in another state)), I think. And he told me about the various protocols.” (Physician, 0129)
Consult other physicians
Determine cost
Planning for Death
Determine who will be present for the death	“That’s why we had a doctor and a social worker at the house at the same time, because we thought that this might happen, that the client would not be able to finish the cocktail.” (Physician, 0138) “In the last couple of days, she suddenly couldn’t swallow it that quickly. … I remember we talked about this, I’m like, ‘What are you going to do, what’s the plan if it doesn’t work?’ We spent a lot of time talking about that.” (Physician, 0141) “Even though I’m not the prescriber, we talked a lot about what happens if it doesn’t work. You know, what other medications do you have in the house and who would use them and who would be called. Even our triage office staff made sure everyone had our number. … I think we all felt kind of an individual obligation to make sure that it went the way it was supposed to and the best way to do that was to put all of our heads together and try to preplan as much as we could.” (Physician, 0145)
Determine who will pronounce the death
Make contingency plans
Professional Education
Share experience with AID informally or formally	“I’ve offered to do talks at the CMEs or different situations and [hospital administrators] refused to let me talk about Act 39 at all. I’m not talking about trying to talk them into doing it. I’m just trying to talk to them about if they have a patient who comes in who is interested in it, here is where you can get information on it.” (Physician, 0134)