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Stanford study finds support across ethnicities for physician-assisted death

June 09, 2016

Physician-assisted death was supported by a majority of California and Hawaii residents, regardless of their ethnicity, who responded to an online survey, according to a study by researchers at the Stanford University School of Medicine.

The study also found that older people were more likely than younger people to believe it is OK to allow physicians to prescribe life-ending drugs to terminally ill patients who request them, and that the most religious or spiritual people were the least supportive of this idea. But even among those who declared that religion or spirituality was very important to them, a majority still supported the practice.

The study will be published online June 9 in the Journal of Palliative Medicine to coincide with the date that California's End of Life Option Act takes effect. The act was signed into law Oct. 9, 2015. Physician-assisted death is illegal in Hawaii.

"It is remarkable that in both states, even participants who were deeply spiritual (52 percent) were still in support of physician-assisted death," said the study. "Both genders and all racial/ethnic groups in both states were equally in support of PAD."

'Surprisingly positive'

"The response was surprisingly positive across all ethnic groups," said VJ Periyakoil, MD, clinical associate professor of medicine, who is the lead and senior author of the study. Those taking the survey marked their ethnicities as African American, Latino, white, Native Hawaiian/Pacific Islander or Asian.

"I was surprised that people who were deeply spiritual were still positive overall," she added.

To conduct the study, researchers developed an online survey that asked participants to respond, true or false, to whether they believed it is acceptable to allow a physician to prescribe medication, at the request of a terminally-ill patient, in order to end that person's life.

"We wanted a broad question that didn't specify what kind of medication, that didn't say oral pills or self-administered, none of that," Periyakoil said. Participants were also asked: "How important is your faith/religion/spirituality to you? (Unimportant, somewhat important, important and very important.)"

Participants responded to the online survey, which was housed and stored on a secure Stanford server. Data was collected from July through October 2015.

Among the 1,095 responses from California and 819 from Hawaii, the majority -- both in California (72.5 percent) and Hawaii (76.5 percent) -- were supportive of PAD.

"Older participants were more supportive of PAD compared with their younger counterparts in both states," the study said. "Persons who reported that spirituality was less important to them were more likely to support PAD in both states."

For those who said religion/faith/spirituality was very important to them, about 52 percent were in favor of PAD, the study found.

"The act of deliberately hastening death is not supported by most religions. ... Thus it is not surprising that in our study participants who reported faith to be most important to them were least in support of PAD," the study said.

Need for cultural sensitivity

Periyakoil, an expert on end-of-life care and director of the Stanford Palliative Care Education and Training Program, stressed that it's important for physicians in California to prepare for the new law. In addition to training in end-of-life conversations and being aware of cultural differences, physicians need to be honest with their patients, Periyakoil said.

"Just be upfront," she said. "Tell patients, 'Listen, this is a very hard topic for all of us.'"

In particular, primary care physicians will inevitably be faced with questions from patients, she said.

"It takes a tremendous amount of courage on the patient's part to ask these questions," Periyakoil said. "How the doctor responds initially to the patient's question is very important and will set the tone for the rest of the interaction about this sensitive issue."

The study provides evidence that patients of various ethnicities and religious backgrounds will be seeking information from their physicians on the issue, many of them at what may be the most vulnerable time in their lives, she said.

"We stress that requests from diverse patients have to be approached with great cultural sensitivity," the researchers wrote in the study.

The study asserted that because of the number of complex provisions in the law -- such as the requirement that medication must be self-administered by a mentally competent patient -- it will actually affect only a tiny fraction of seriously ill patients.

This has been borne out in Oregon, which in 1997 became the first state to pass an assisted-suicide law.

"Only a small sliver of the population will be eligible for the End-of-Life Option Act, and of those eligible, only a portion are likely to utilize this option, and no one ethically opposed would likely do so," the study said. "For example, of the 34,160 Oregonians who died in 2014, only 155 received a lethal prescription and 105 utilized it."

Although long-debated in California, the issue of physician-assisted death gained momentum after Brittany Maynard, a 29-year-old Californian who was terminally ill, decided to move to Oregon in 2014 to end her life rather than suffer the pain and debilitation caused by brain cancer.

"As California is a highly populous majority-minority state, we are soon going to learn how diverse racial and ethnic groups respond to legalizing physician-assisted death," Periyakoil said. "In order to alleviate suffering for all seriously ill patients, it is extremely important that we also provide excellent palliative care early in the illness process."

Periyakoil's teaching module on physician-assisted death, which is posted on the medical school's website, is designed to be used as a discussion aid for both patients and physicians. It is available at

The other Stanford co-authors of the paper are Helena Kraemer, PhD, professor emerita of biostatistics in psychiatry, and analyst Eric Neri.
Periyakoil's work is supported by the Veterans Administration Palo Alto Health Care System and the National Institute on Minority Health and Health Disparities (grants R25MD006857 and U54MD010724).

Stanford's Department of Medicine also supported the work.

The Stanford University School of Medicine consistently ranks among the nation's top medical schools, integrating research, medical education, patient care and community service. For more news about the school, please visit The medical school is part of Stanford Medicine, which includes Stanford Health Care and Lucile Packard Children's Hospital Stanford. For information about all three, please visit

Print media contact: Tracie White at (650) 723-7628 (
Broadcast media contact: Margarita Gallardo at (650) 723-7897 (

Stanford University Medical Center

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