1 Advance Care Planning and Physician Assisted Suicide in Minnesota: The State of the Questions St. Raphael’s Guild, Presentation and Discussion Holy Rosary Cathedral Sunday, December 4, 2016 Jonathan R. Sande, MD Director, Essentia Health Advance Care Planning Director, SMMC Ethics Program Essentia Health Cancer Center

2 No Disclosures Per corporate compliance neither Sandee nor I have financial conflicts of interest

3 Objectives Define advance directive (AD), advance care planning (ACP), hospice, palliative care, physician assisted suicide (PAS), and “aid in dying” Present rationale for ACP at Essentia Health (EH) Summarize status of ACP at EH and in Minnesota Summarize status of PAS internationally, nationally, and in Minnesota Present ethical arguments for and against PAS Discuss three issues the recent Minnesota PAS legislation underscored Present patient-centered strategies to consider when patients ask about PAS Whither medicine, health, and health care? After listing objectives state something like… implementing ACP is an ambitious undertaking involving the breadth and depth of the organization. We present what we feel are the most important points for your consideration; the references provide other resources, and either or both of us would be more than happy to meet with you to discuss ACP in more detail.

4 Outline Advance Care Planning (ACP) Definitions (AD, ACP)Why ACP at EH ACP overview Status of ACP at EH and statewide Physician Assisted Suicide (PAS) Important definitions (Hospice, Palliative Care, PAS, and “aid in dying”) Current international, national, and state contexts Ethical arguments for and against PAS Three concerns raised by recent Minnesota PAS legislation Status of PAS in Minnesota Practical responses Discussion After listing objectives state something like… implementing ACP is an ambitious undertaking involving the breadth and depth of the organization. We present what we feel are the most important points for your consideration; the references provide other resources, and either or both of us would be more than happy to meet with you to discuss ACP in more detail.

5 Definitions – Advance Directive (AD)Also known as… Healthcare Directive, Durable Power of Attorney for Healthcare Less commonly “Combined Directive,” “Living Will” An AD is NOT EQUIVALENT TO a POLST ORDER AD is “an” “indication” of a person’s wishes for future medical care…

6 Definitions-AD An indication of a person’s wishes for future medical care… Could be informal, oral, casual… Could be formal, written, legally recognized… An “ideal” AD Is a frequently updated outcome of ongoing conversations between patient and loved ones regarding patient’s goals and values for healthcare Names an appropriate agent(s) Gives direction to agent(s) regarding goals and values for healthcare decisions

7 The Unfulfilled Promise of ADs…Patient Self Determination Act (PSDA) enacted 1991 Studies vary; average completion < 30% Haphazard, left to whim of patient and/or health care professional Multiple barriers: patient/family, health care professional/system, culture… Even if AD completed studies show low agreement between patient choice and what agent believes patient would want; even lower agreement between patient choice and patient’s physician’s prediction Lack of AD can lead to increased family stress, grief, and discord after patient death

8 Definitions – ACP A patient and family centered, organized process of communication to help individuals understand, reflect upon, and discuss goals of care for future healthcare decisions in the context of their values and beliefs. Hammes/Briggs, 2011

9 Definitions-ACP Based on “Five Promises”“We will initiate the conversation…” “We will provide assistance…” “We will make sure plans are clear…” “We will maintain and retrieve these plans…” “We will appropriately follow these plans…” Hammes/Briggs, 2011

10 Definitions-ADs and ACPTHE MERE PREPERATION OF AN ADVANCE DIRECTIVE IS UNLIKELY TO BE EQUIVALENT TO WELL DONE ADVANCE CARE PLANNING…

11 Why ACP at EH? Seeds in hundreds of ethics consultations at SMMC since 2003 The need to assist patients/families “upstream” to try to prevent unnecessary suffering became very clear… Vocation of “healing”… Personal… Professional… Institutional…

12 Ethical and Religious DirectivesPart III, Professional-Patient Relationship 27: Free and informed consent requires that the person or the person’s surrogate receive all reasonable information about the essential nature of the proposed treatment and its benefits; its risks, side-effects, consequences, and cost; and any reasonable and morally legitimate alternatives, including no treatment at all. 28: Each person or the person’s surrogate should have access to medical and moral information and counseling so as to be able to form his or her conscience. The free and informed health care decision of the person or the person’s surrogate is to be followed so long as it does not contradict Catholic principles.

13 Ethical and Religious DirectivesPart Five: Issues in Care for the Seriously Ill and Dying, Preamble: …Physicians and their patients must evaluate the use of technology at their disposal. Reflection on the innate dignity of human life in all its dimensions and on the purpose of medical care is indispensable for formulating a true moral judgment about the use of technology to maintain life. The use of life-sustaining technology is judged in the light of the Christian meaning of life, suffering, and death. In this way two extremes are avoided: on the one hand, an insistence on useless or burdensome technology even when a patient may legitimately wish to forgo it and, on the other hand, the withdrawal of technology with the intention of causing death.

14 Ethical and Religious DirectivesPart V (continued): 55: Catholic health care institutions offering care to persons in danger of death from illness, accident, advanced age, or similar conditions should provide them with appropriate opportunities to prepare for death. Persons in danger of death should be provided with whatever information is necessary to help them understand their condition and have the opportunity to discuss their condition with their family members and care providers. They should also be offered the appropriate medical information that would make it possible to address the morally legitimate choices available to them. They should be provided the spiritual support as well as the opportunity to receive the sacraments in order to prepare well for death.

15 Why ACP at EH? East End of Life Initiative FY 2012Our service to patients/families approaching end of life needed significant improvement Recommendation to East Senior Leadership Team in April 2012 Excellent end of life care for our patients/families requires: Implementation of the most effective system wide ACP approach available Creation of robust palliative care services to complement our hospice services

16 Why ACP at EH? Leadership Team approved unanimously“Triple Aim of Healthcare” (Accountable Care Organizations) Improve patient experience Improve quality Decrease costs Well done ACP is a very powerful form of patient centered family oriented care Essentia is called to well done ACP… By the needs of our patients/families By the Ethical and Religious Directives for Catholic Health Care Services By our Mission/Vision/Values Support continues… “Quadruple” aim… ACP emerging as a national priority

17 Why ACP at EH? Institute of Medicine, “Dying in America,” September 2014

18 “Dying in America” The controversy on this topic and the political desire to avoid it do not alter the fact that every person will face the end of life one day, and many have had hard experience with the final days of a parent, a spouse, a child, a sibling, another relative, or a dear friend. At a time when public leaders hesitate to speak on a subject that is profoundly consequential for the health and well-being of all Americans, it is incumbent on others to examine the facts dispassionately, assess what can be done to make those final days better, and promote a reasoned and respectful public discourse on the subject. p. ix

19 Essentia Health Mission/Vision/ValuesWe are called to make a healthy difference in people’s lives Vision Essentia Health will be a national leader in providing high quality, cost effective, integrated health care services Values/Behaviors… Quality Hospitality Respect Stewardship Justice Teamwork JOY?

20 ACP at EH Respecting Choices® (RC) Gundersen Lutheran Medical Foundation, LaCrosse, WI Continuous development since 1991 Most recognize RC as international standard for ACP Allina, Kaiser Permanente; Australia, Singapore, Germany, recent $8.5 million EU study… August 2013, after review, discussion, discernment EH East signed implementation contract with RC limited to “Next Steps”

21 ACP at EH: RC “Steps” Approach“First Steps” All patients > 55 (e.g.); subsequently readdressed annually, or if significant change in health care status “Next Steps” (Disease-Specific) Patients with life-limiting illness(es) likely to require increased health care professional encounters and to suffer complications and functional decline “Last Steps” Patients who are hospice appropriate

22 POLST (MOLST, …) Not an Advance DirectiveRather a signed health care professional order originally designed for use limited to: those with a terminal illness (less than 12 months); and who have had a full and documented discussion regarding goals and values around end of life care choices National effort to promote use Concerns around potential abuses have been raised by many, including the Catholic bishops of Minnesota and Wisconsin EH does not promote the use of POLST, but acknowledges the need to address out of hospital resuscitation issues in life limited situations

23 “First Steps”® For healthy adults, age (> 50…)20-30 minute facilitated conversation with patient and agent around an unexpected neurologic injury in which patient unable to communicate and recovery unlikely Conversation around three main issues choosing an appropriate agent identifying cultural, religious, spiritual and personal beliefs influencing treatment decisions exploring goals of care for a severe, permanent brain injury with expected poor cognitive outcome Completion of an advance directive

24 “Next Steps”® Extensively scripted research based; six stages; minutes Technique is non-directive empathic listening, to identify and clarify patient’s beliefs, values, and goals in the face of life limiting illness and potential complications General flow understand patient’s illness beliefs, values, hopes, and goals, including spiritual resources/needs assess patient experiences with: recent hospitalizations; caring for others with serious illness re-affirmation of agent discussion of treatment preferences in life-limiting scenarios completion of AD; necessary referrals; documentation

25 “Next Steps”® Stage IV, Clarify Goals for Life-sustaining Preferences (15-30 minutes): explore treatment preferences in hypothetical scenarios using previously identified beliefs, values, and goals 1: high burden (long intense) hospitalization, low survival (<5%) 2: high chance survival but significant physical disability (no walk/talk or both, and need 24 hour care), cognition intact 3: high chance survival needing 24 hour care but severe cognitive dysfunction (patient will not know who/where they are) 4: CPR discussion 5: Ventilation discussion

26 Current Status ACP at EHACP an institutional priority at EH, with strong administrative support Systems built (ACP navigator in EMR [Epic], order sets, data monitoring, patient and agent satisfaction surveys, …) Program Director and Program Coordinator Next Steps® facilitators embedded in specialty sections; standardizing Next Steps® in EH East Specialty Clinics Coordinating/developing system wide ACP building First Steps® ACP into primary care Annual Wellness Visits standardizing goals of care documentation, handling of documents, and resuscitation orders throughout system Rural Community ACP Pilot - Ely, MN Pediatric ACP Pilot

27 Current Status ACP in MinnesotaSignificant momentum statewide… Honoring Choices Minnesota State wide grant from legislature Minnesota Medical Association (MMA) “End of Life Collaborative” Now entitled “Advancing Serious Illness Goals Of Care Initiative” Curricula around shared decision making in serious illness Twin Ports EH and SLH partnering (early stages) to promote high quality community/regional ACP

28 Physician Assisted Suicide (PAS)Important definitions (Hospice, Palliative Care, PAS, and “care in dying”) Current international, national, and state contexts Ethical arguments for and against Concerns raised by PAS legislation Practical responses Discussion After listing objectives state something like… implementing ACP is an ambitious undertaking involving the breadth and depth of the organization. We present what we feel are the most important points for your consideration; the references provide other resources, and either or both of us would be more than happy to meet with you to discuss ACP in more detail.

29 Definitions - Hospice Hospice care is supportive, whole person care offered when people have a terminal illness and limited life expectancy (6 months or less, but often people do well, live longer and even discharge from hospice). Hospice focuses on quality of life, aggressive symptom management and medical, social and spiritual support for patient and family.

30 Definitions – Palliative CarePalliative care is whole-person care for people with serious chronic illness or life threatening illness which is offered together with treatments designed to prolong life, or with curative treatments. The intent is to provide an extra layer of support for the patient and medical team. The focus is on quality of life, symptom management, planning for the future and aligning medical goals with personal goals and values.

31 PAS International ContextPAS and euthanasia… Germany (assisted suicide legal since 1751; German Medical Association prohibits physician participation; no euthanasia…) Switzerland (1918 [42?]; original law permitted assisted suicide in matters of “honor and romance”; do not have to be ill, some clinics accept foreign patients; no euthanasia) Colombia 1997 (highest court opened to euthanasia and PAS; to this point no legislative guidance) Emanuel, “Euthanasia and physician-assisted death”; UpToDate;

32 PAS International ContextPAS and euthanasia… Netherlands (2002; euthanasia legal, including children > 12) Belgium (2002, extended to children of any age in 2008/2014[?]; euthanasia legal) Luxembourg (2008; euthanasia legal, including children > 12) Canada (2015 court ruling; February 2016 PAS and euthanasia become legal; Canadian Supreme Court Ruling Jun 6, 2016[?]; Quebec legalized PAS and euthanasia in 2014) Chochinov; Emanuel; op cit.

33 PAS National Context United States Supreme Court has heard several cases regarding PAS In 1997 Supreme Court ruled there was no “constitutional right” to PAS, and empowered/encouraged states to make decisions At that time the majority of states had laws most interpreted as making PAS criminal Activity now at level of individual states Since 1997 increasing activity at the state level, with over half considering PAS legislation recently

34 PAS National Context States with authorized PAS Oregon (1997)Washington (2008) Vermont (2013) California (2015) Colorado (2016) Emanuel, op cit. Quill/Battin, “Responding to Requests,” UpToDate

35 PAS National Context Legal standing supporting PASMontana, statewide (2009; Montana supreme court ruling that existing law protects physicians giving lethal prescriptions; that is PAS is not illegal) New Mexico, provisionally only Bernalillo County (2014; court ruling protects “right to die”; to be heard by New Mexico Supreme Court October 2015[?]) Emanuel, op cit. Quill, op cit.

36 PAS National and State ContextCompassion & Choices organization Formed in 2007 from merger of “Hemlock Society” and “Compassion and Dying” President Barbara Coombs Lee, PA, FNP, JD “Compassion & Choices [C&C] is the leading national nonprofit organization dedicated to improving care and expanding choice for people with advanced illness, and nearing or at the end-of-life. We work to change attitudes, practices and policies so that everyone can access the information and options they need to have more control and comfort as life ends.” https://www.compassionandchoices.org/userfiles/Federal-Policy-Agenda.pdf; https://www.compassionandchoices.org/what-we-do/in-the-courts/

37 PAS National and State Context“We offer free consultation, planning resources, referrals and guidance, and across the nation we work to protect and expand end-of-life options. We also advocate for policies at the federal level that will improve person centered care for those with advanced illness and approaching death.” C&C strategy includes “innovative legal advocacy” and “impact litigation” https://www.compassionandchoices.org/userfiles/Federal-Policy-Agenda.pdf https://www.compassionandchoices.org/what-we-do/in-the-courts/

38 PAS State and Local ContextC&C Minnesota activity Duluth Public Library, 11/12/14 “Are You Good to Go? Understanding Your End-of-Life Options” “Roland Halpern, Regional Campaign & Outreach Manager for [C&C], will discuss end-of-life planning and the currently available end-of-life options in Minnesota. Free and open to the public.” https://www.compassionandchoices.org/what-you-can-do/get-involved/are-you-good-to-go-understanding-your-end-of-life-options /

39 PAS State and Local ContextMarch 2015 initial public event announcing Minnesota Compassionate Care Act of 2015 (SF1880) Substantial portions of SF1880 identical to sample legislation in C&C “Lawmakers Guide: Drafting Aid-in-Dying Legislation” SF1880: Eaton, Pappas, Dibble, Marty, and Goodwin HF2095: Freiberg, Schultz, Kahn, Laine, Loeffler and others https://www.compassionandchoices.org/userfiles/CC-Legislative-Packet.pdf SF1880 HF2095

40 PAS State Context SF1880 heard and withdrawn at last session; recent election results suggest successful legislation in Minnesota in near future unlikely... A “Compassion and Choices” strategy is to convince state medical associations to move to at least neutral, if not in favor of PAS; MMA is considering moving from opposed to neutral; many have signed a petition to the MMA to remain opposed “Minnesota Alliance for Ethical Healthcare” (http://ethicalcaremn.org/about/) 34 organizations have joined to resist PAS and promote better alternatives Letter to MMA encouraging opposition to PAS …

41 PAS Ethics Context Distinctions in US medical ethics in the last seventy years… Killing vs letting die Active vs passive euthanasia; direct vs indirect euthanasia Voluntary active euthanasia (patient requests) Involuntary active euthanasia (patient does not request) Nonvoluntary active euthanasia (patient can not request) Human dignity vs death with dignity “Aid in dying” vs physician assisted suicide (PAS)

42 PAS Ethics Context Terms used to discuss PAS are used in different ways by different persons… This results in confusion This confusion affects: Studies/surveys Quality of discussion Patient-professional relationships Patient care Trust

43 PAS Ethics Context “Although euphemisms ring more gently, the cost may be a loss of clarity. A 2015 study indicated that only 40% of 271 Quebec health care professionals realized that medical aid in dying would allow them to administer lethal medication at the patient's request.” Chochinov, “Physician-Assisted Death.” JAMA. 2016;315(3): doi: /jama

44 PAS Ethics Context Ethics concepts important to PAS AutonomyBeneficence Primum non nocere “Double Effect” Commission/Omission Intention Patient competence/capacity “Professional ethic”

45 PAS Ethics Context Ethics concepts important to PAS CompassionHuman Dignity Professional competence Patient-professional relationship Personal Integrity Veracity (truth telling) Trust

46 PAS Ethics Context Arguments Pro PAS Autonomy/ControlSuffering (has no meaning, it is to be avoided) Doctors make us suffer at the end; can’t trust doctors/health care system; patients need PAS for protection from doctors and the health care system Beneficence There (is no) “professional ethic”

47 PAS Ethics Context Arguments Pro PASEthical distinctions (are) sophistic “Slippery Slopes” (haven’t, and won’t happen) Palliative care/hospice (demand for PAS will improve) Autonomy > Human dignity Patient-professional relationship is a “contract” (do what patient wants; professional’s values have little/no standing) It’s happening anyway so legalize it… …and make it transparent

48 PAS Ethics Context UMD Center for Ethics and Public Policy event on October 9, 2015 Chris A. Eaton (autonomy/control; eliminate suffering) David J. Mayo (philosophical defense of PAS) Eaton and Mayo, https://sites.google.com/a/d.umn.edu/cepp/videos

49 PAS Ethics Context Arguments against PAS…Autonomy (it is irrational/inconsistent for a human to act to end the conditions of possibility for autonomy; that is, life) Beneficence There (is a) “professional ethic” Ethical distinctions (are not) sophistic

50 PAS Ethics Context Arguments against PAS…“Slippery Slopes” (have, and will continue to, happen) Palliative care/hospice (need more to prevent requests for PAS) Suffering (is to be minimized as much as possible, but is unavoidable in being human and has meaning…) Human dignity > Autonomy Patient-professional relationship is a sacred covenant All human life is unconditionally sacred

51 PAS Ethics Context UMD event, Kirk Allison:Negatively transforms medical practice Corrupts physicians, and medical and public health records Endangers vulnerable patients Glosses over issues of errant diagnoses and prognoses Negative spillover (increases) other suicides Proposed legislation [and current practices in the Northwest] makes investigation of malfeasance almost impossible Allison https://sites.google.com/a/d.umn.edu/cepp/videos

52 Issues Raised… LanguagePhysician assisted suicide: “Suicide carried out with the assistance of a physician (whose role is typically to provide a lethal dose of a drug at the explicit, voluntary request of a mentally competent patient)” suicide?q=physician-assisted+suicide Aid in dying: “…the medical practice of a physician prescribing medication to a qualified patient who is terminally ill, which medicine a qualified patient may self-administer to bring about the patient’s own death” SF1880;

53 Issues Raised… LanguageC&C, “Aid in Dying: Primer for Candidates” in “Language Matters,” from a section entitled “The S Word” “Aid in dying is not assisted suicide. It is critical to accurately describe this medical option that dying people can access to end their suffering. Dying people who consider using aid in dying find the suggestion that they are committing suicide deeply offensive, stigmatizing and inaccurate. Many have publicly expressed that the term is hurtful and derogatory to them and their loved ones. Many medical groups agree and have adopted the term aid in dying.” https://www.compassionandchoices.org/userfiles/C-C-Candidate-packet.pdf

54 Issues Raised… Language“The assisted suicide statutes that many states have on the books are not intended to address aid in dying. They are designed to stop people from helping mentally unbalanced, despondent people kill themselves. Neither the statute nor the term accurately applies to terminally ill people who want to live, but given their imminent death, choose to die peacefully. State laws authorizing aid in dying clearly state they do not authorize assisted suicide.” https://www.compassionandchoices.org/userfiles/C-C-Candidate-packet.pdf

55 Issues Raised… Death Certificates“The attending physician may sign the qualified patient’s death certificate that shall list the underlying terminal illness as the cause of death.” SF1880; Recall Allison’s contention that PAS “corrupts physicians, and medical and public health records” and “proposed legislation [and current practices in the Northwest] makes investigation of malfeasance almost impossible”

56

57 Issues Raised… Data MonitoringSF1880/HF2095 had no provisions for data monitoring Proponents of such laws routinely state how well the practice is monitored in Oregon, and that no problems have arisen Some have suggested that monitoring is not necessary

58 https:// https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf

59 https://public. health. oregonhttps://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf

60 https://public. health. oregonhttps://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf

61 Essentia Health PerspectiveEssentia Health is committed to a different vision of health care than is implied by the proposed legislation. We believe our vision leads to better patient- and family-centered care, particularly at end of life. This vision includes fully developed and integrated palliative care, hospice, and advance care planning services, and a holistic and intensive approach to reduce suffering in all of its forms—physical, emotional, financial, social, and spiritual. Modified from Sande; https://sites.google.com/a/d.umn.edu/cepp/videos

62 Essentia Health PerspectiveEssentia Health’s Catholic facilities follow the Ethical and Religious Directives for Catholic Health Care Services Essentia Health was created in dialogue with our founding organizations and our Benedictine sponsors. Our organizational commitments do not allow abortion, physician assisted suicide, or euthanasia by any Essentia Health facility or employee Essentia Health will honor these commitments Ethical and Religious Directives

63 Practice RecommendationsIt starts at the beginning, from before you walk in the room the very first time… Demonstrate that you already “know” the patient by your review of their chart, and are competent to handle their problem, or you will get them to someone who can.. Assess what the patient/family understand about their situation, how much they want to understand, and offer to share “the whole story” with them from the very beginning, including prognostic information Demonstrate that you care more about the patient than “the disease” from the start…

64 Practice RecommendationsIf a request for hastened death does arise… Explore explicitly, with compassion (in the older sense; “to accompany in suffering”), without judgment or hurry… What drives the request… what are the fears… Why now… What is happening in supportive relationships… Psychological/psychiatric/financial issues… Explore their values and their views of suffering… Look for unmet symptoms or needs… Re-explore understanding of disease and their understanding of the dying process… PAL31.

65 Practice RecommendationsWork to know your own biases, issues, trigger points, and limits… Get help for your patient... palliative care, hospice… Get help for you… palliative care, ethics, trusted colleague[s] Learn from every situation… To be continued… PAL31. Quill/Battin, op cit.

66 Contact Information Jonathan R. Sande, MD Med Direct at any time Cell

67 Bibliography – ACP “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” The Committee on Approaching Death: Addressing Key End-of-Life Issues. Institute of Medicine of the National Academies. Washington, D.C.: The National Academies Press, [Prepublication Copy: Uncorrected Proofs]. Ethical and Religious Directives for Catholic Healthcare Services, 5th edition, accessed 12/14/14. Hammes, Bernard J. and Linda Briggs. Building A Systems Approach to Advance Care Planning, Gundersen Lutheran Medical Foundation, Inc. La Crosse: 2011. Institute for Healthcare Improvement, accessed 12/10/14. Patient Self Determination Act, HR4449, Found at Accessed 10/3/2013. Sande, JR. “Crucial Conversations, Adaptive Challenges, Advance Care Planning, and Essentia Health – East,” 0700 Grand Rounds, 10/4/13; available through theSource CME Enduring Materials. Sande, JR. “Advance Care Planning: Past, Present, and Future,” Noon Grand Rounds, 11/24/14; available through theSource CME Enduring Materials.

68 Bibliography - PAS Chochinov, Harvey Max. “Physician-Assisted Death in Canada.” JAMA. 2016;315(3): doi: /jama “Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life,” The Committee on Approaching Death: Addressing Key End-of-Life Issues. Institute of Medicine of the National Academies. Washington, D.C.: The National Academies Press, [Prepublication Copy: Uncorrected Proofs]. Ethical and Religious Directives for Catholic Healthcare Services, 5th edition. Ezekiel J. Emanuel. “Euthanasia and physician-assisted death”; UpToDate; updated 10/19/15; accessed 1/26/16

69 Bibliography - PAS http://ethicalcaremn.org/about; accessed 12/4/16 accessed 1/24/16 https://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year17.pdf; accessed 1/26/16 https://sites.google.com/a/d.umn.edu/cepp/videos; accessed 1/24/16 accessed 1/23/16 https://www.compassionandchoices.org/userfiles/C-C-Candidate-packet.pdf; accessed 1/25/16 https://www.compassionandchoices.org/userfiles/CC-Legislative-Packet.pdf; accessed 1/25/16 https://www.compassionandchoices.org/what-you-can-do/get-involved/are-you-good-to-go-understanding-your-end-of-life-options /; accessed 1/27/16

70 Bibliography - PAS https://www.compassionandchoices.org/userfiles/Federal-Policy-Agenda.pdf; accessed 1/25/16 https://www.compassionandchoices.org/what-we-do/in-the-courts/; accessed 1/25/16 accessed 1/27/16 accessed 1/26/16 accessed 1/27/16 accessed 1/27/16 The Minnesota Compassionate Care Act of 2015 (HF2095). Available at

71 Bibliography - PAS The Minnesota Compassionate Care Act of 2015 (SF1880). Available at Timothy E. Quill, MD, and Margaret P Battin, MFA, PhD; Responding to requests for physician aid in dying,”UpToDate; updated 10/15/15; accessed 1/25/16