Implementation of the California End of Life Option Act at UCSF: Examining the Utility of the Mandatory Mental Health Assessment in Medical Aid in Dying.

Background: The End of Life Option Act (EOLOA) legalized medical aid in dying (MAID) in California in 2015. University of California, San Francisco Health initially implemented a policy requiring a mandatory mental health assessment of all patients seeking MAID, though this was not required by the EOLOA. State-level statistics on EOLOA are available, but less is known about outcomes at individual institutions and how institutional policy affects outcomes for patients seeking MAID.

Objectives: Investigators examined the factors contributing to patients' decisions to request MAID and how the mandatory mental health assessment impacted determinations of decisional capacity and access to MAID.

Methods: Retrospective chart review was conducted on a sample of patients who had pursued MAID or been prescribed MAID medications between June 2016 and May 2020 obtained by a combination of purposive sampling (n = 78) and systematic electronic health record sampling (n = 22). Descriptive statistics were used to examine demographic factors, neuropsychiatric diagnoses and rating scales, factors contributing to patients' decision to request MAID, and outcomes of the psychiatric evaluation process.

Results: Of the 78 patients in the purposive sample who had initiated EOLOA requests, 67% had MAID medications prescribed. Zero patients were found to lack decisional capacity due to a current psychiatric condition. Many patient records were missing relevant data including neuropsychiatric rating scale scores and factors contributing to patients' decision to request MAID. The neuropsychiatric rating scale scores and diagnoses that were present did not suggest a high prevalence of severe psychiatric illness in the sample.

Conclusions: The findings from this study suggest that mandatory mental health assessments for all patients requesting MAID at a single academic medical center did not identify patients who lacked decisional capacity to pursue MAID, and potentially created access barriers to seriously ill patients seeking this intervention. Generalizability of findings may be limited by the fact that mental illness burden was low in the studied sample. Results from this study contributed to changes in EOLOA institutional policy at University of California, San Francisco, including elimination of the mandatory mental health assessment for EOLOA candidates in favor of a conditional mental health assessment based on certain clinical criteria.