In a major step forward for the right-to-die proponents, California Governor Jerry Brown signed legislation Monday allowing doctors to prescribe life-ending medication to dying patients, making the state the fifth to legalize the practice and the first since the death of Brittany Maynard, whose decision to leave the state to end her life last year lent new urgency to the death with dignity movement.

The law allows doctors to prescribe life-ending medication to patients who have been given six months or less to live. It requires two doctors to consent to the prescription as well as written requests from the patient for the medication. California joins Oregon, Washington, Vermont and Montana, which also allow the practice.

While polls show 3 out of 4 voters in California say they are pleased with the law, others say this bill is only one piece of the puzzle, that when you take the issue of palliative care leading up to death as a whole the US is far behind other nations. They are making calls for the entire process around death and dying to be addressed as part of the conversation. Currently in many parts of the country patients have to end cancer or other life prolonging treatments before they can qualify for hospice or other palliative care.

Need for Palliative Care Concern around the World

This comes at the same time as a new international study sponsored by the The Lien Foundation calls on governments and policy makers to hasten and improve their provision of palliative care based on key findings of the 2015 Quality of Death (QOD) Index by the Economist Intelligence Unit:

National palliative care policies and strategies are vital for extending access to palliative care. Many top-ranked countries have comprehensive frameworks that integrate palliative care into the healthcare systems. For example, Chile (27th) integrates palliative care into its healthcare services and has policies for opioid access.

Many top-ranked countries have comprehensive frameworks that integrate palliative care into the healthcare systems. For example, Chile (27th) integrates palliative care into its healthcare services and has policies for opioid access. Estimates show fewer than 10% of those who require palliative care actually receive it. The Index also highlighted that even top-ranked nations “struggle to provide adequate palliative care services for every citizen”

The Index also highlighted that even top-ranked nations “struggle to provide adequate palliative care services for every citizen” Palliative care needs investment but offers savings in healthcare costs. Recent research has shown how early introduction of palliative care can reduce healthcare costs over the long term.

Recent research has shown how early introduction of palliative care can reduce healthcare costs over the long term. Even though income levels are a strong indicator of the availability and quality of palliative care, less wealthy countries can still improve standards of palliative care quickly . Mongolia (28th), Panama (31st) & Uganda (35th) advanced in palliative care through innovation and individual-led initiatives.

. Mongolia (28th), Panama (31st) & Uganda (35th) advanced in palliative care through innovation and individual-led initiatives. Demand for palliative care will grow rapidly in some countries that are ill-equipped to meet it . Countries like Hungary (41st), Greece (56th) & China (71st) have limited supply but rapidly increasing demand for palliative care. They will need active investment to meet public needs.

. Countries like Hungary (41st), Greece (56th) & China (71st) have limited supply but rapidly increasing demand for palliative care. They will need active investment to meet public needs. Community engagement is crucial for raising awareness and encouraging conversations about death. Taiwan (6th) successfully used mainstream and social media to increase awareness of palliative care.

“Palliative care has to be a fundamental pillar of a humane healthcare system, guided by the duty to relieve suffering,” said Mr. Lee Poh Wah, Lien Foundation’s Chief Executive Officer, “It is incumbent upon each of us to dig deeper and remove the barriers buried in our healthcare systems, institutions, and cultural practices; as well as demand greater accountability from our governments to improve care for the dying.”

Conclusions on US Palliative System

The US ranked 9th in the study and they found that palliative care has been in development over a relatively long period in the United States. Services have expanded, providing high-quality coverage and legal protection of patients’ rights. The system is open and transparent, but not universally affordable.

The study concluded that the US palliative national strategy is not government-led. It has fallen to independent organisations have devised a plan to strengthen and expand services on a national level. Public funding is available for research, although it is declining. A serious concern is that the number of specialists falls short of patient needs. There is only one palliative medicine physician for every 1,200 terminally ill patients.

Opponents to New Law

While many hail the California law as a step forward towards better end of life care in the US, not everyone was happy with the new law. On its website, Californians Against Assisted Suicide lists dozens of organization opposed to the bill Brown signed Monday. They include the American Academy of Medical Ethics, the American Medical Association, the California Catholic Conference, the Disability Rights Center and many others.

“We all know that ‘choice’ is a myth in the context of our unjust health care reality,” the group said after the state Senate passed the bill last month. “End-of-life treatment options are already limited for millions of people — constrained by poverty, disability discrimination, and other obstacles.

“Adding this so-called ‘choice’ into our dysfunctional health care system will push people into cheaper lethal options.” Opposition also came from disability rights advocates who say the practice can open the door to abuses of the elderly and disabled, as well as the Catholic Church, which says only God should decide when people should die.

As Gov. Jerry Brown pointed when he signed the legislation on Monday, the End of Life Option Act is not just any other piece of legislation: By definition, it’s a matter of life and death.

“The crux of the matter is whether the state of California should continue to make it a crime for a dying person to end his life,” Brown said in an unusual signing message, “no matter how great his pain and suffering.”

Until Brown signed the law he hadn’t indicated where he stood on the issue. Until he explained that his decision was personal, based on his reflections “on what I would want in the face of my own death.”

“I do not know what I would do if I were dying in prolonged and excruciating pain,” he wrote in the message, addressed to state Assembly members. “I am certain, however, that it would be a comfort to be able to consider the options afforded by this bill. And I wouldn’t deny that right to others.”

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Lindsey McCoy MPA, is an Executive Medical Recruiter and former CEO in the not for profit sector.