Table 4.

Hospital Reports of Challenges and Possible Solutions Implementing the End of Life Option Act

Challenges		Possible solutions
Providers unavailable
Physicians (attending, consulting, and specialist)	Oncology is not excited to participate and palliative care opted out. Need to identify which hospices will participate.	Nurtured referral pool. We provide support to those providers and invest in education to address nonparticipation concerns. Have a system set up so that if the first provider is not willing or able, local teams will set up. This leaves room for people to opt out, but still ensures access. Did a lot of upfront educational work, peer group meetings, and now local team meetings.
Other health professionals	Many willing participants in this area. The problem is with finding pharmacies.	Have created an information line. Lessening with time. With more experience and education, more providers are willing to participate.
Difficult process
Implementing a complex process	It is a real struggle to figure out how to implement this law in an acute care facility whose mission is to save lives, not end them. It is a difficult process. We also need more support for documentation in the electronic medical record. Providers think it is too much paperwork (e.g., fill out follow-up forms, even if patient does not take the meds).	Configure it as a process that should be clear to patient, family, and providers—even if never done it before. The goal is to shepherd them through the process, which the patient coordinator helps with quite a bit. The local team makes sure all understand the process and documentation. This can be a challenge if patient wants a quick decision or declines quickly. The situation can become more urgent, but we cannot make it happen any faster because of the conditions in the law.
Lack of clarity from legal perspective	Many operational aspects are not addressed in the law. The law is geared toward physicians, but most places take this on as an institution. The language around the attending physician is not clear and there are challenges to getting appointments for all steps.
Distressed providers
Compelled to participate	Providers were distressed because they thought they would be compelled to participate.	Education, comfort on the part of the physician is critical.
Change in physician role and practice	The law requires that the patient make the request (not a surrogate), which differs from every other aspect of end-of-life care. Also, when the patient asks the doctor not to tell the family members about the request, this causes distress for the provider. Recognition of being directly responsible for a patient's death.	Want to honor the decisions of providers to opt in or opt out, but also leave room for them to change their mind as they go. We take this on a case-by-case basis, so if there is moral distress, we do not want providers to feel cornered. There is always someone else who can help. Some hospice providers have felt like this is too much of a departure from their normal way of operating, so doing debriefs as needed. Use Schwartz rounds to address issues for providers, from a range of backgrounds and positions.
Increased workload	Two people who will prescribe—they feel that it is unfair that they are the only ones.
Distressed patients or family members
Patients who do not qualify	When patients want to enroll and cannot (ALS, esophageal tubes, because they cannot swallow), but they have capacity.	Mostly when physicians are not participating. Created a coordinator role that helps to provide information and referrals.
Duration of the process	The process takes time and some patients are very far along in their illness.
Cost	Typically, money is the most distressing issue. Family issues—we had a case where extended family members were not included in decision making and were very upset. Also, how to pay for it when insurance does not cover it.
Medications
Compounding	…prescriptions are hard to get. Secobarbital is hard to find and they do not work with a compounding pharmacy.	All requests go through our own pharmacy, which is staffed with a pharmacist and a LCSW. It can also be challenging to take the medications, so we have a pharmacist come and out and walk through all the directions and answer any questions.
Aid-in-dying medication regimen	Knowing the right cocktail is challenging, as is the cost of medications. There may be problems with unequal access given the costs.
Disposal if unused	Some concerns about the meds if patient status changes or they do not use the meds.	…working with a system-wide taskforce to create pharmacy guidelines.

Survey conducted at the hospital level 15–21 months after implementation of the EOLOA. Table includes direct quotes from respondents.