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Executive Summary
California’s End of Life Option Act (EOLA) became effective on June 9, 2016. The Act
allows terminally ill adults living in California to obtain and self-administer aid-in-dying
drugs.
1
The Act requires the California Department of Public Health (CDPH) to provide
annual reports under strict privacy requirements. CDPH’s reporting requirements are
outlined in Health and Safety Code section 443.19 (b), which reads:
(b) On or before July 1, 2017, and each year thereafter, based on the information
collected in the previous year, the department shall create a report with the
information collected from the attending physician follow up form and post that report
to its Internet Web site. The report shall include, but not be limited to, all of the
following based on the information that is provided to the department and on the
department’s access to vital statistics:
(1) The number of people for whom an aid-in-dying prescription was written.
(2) The number of known individuals who died each year for whom aid-in-dying
prescriptions were written, and the cause of death of those individuals.
(3) For the period commencing January 1, 2016, to and including the previous year,
cumulatively, the total number of aid-in-dying prescriptions written, the number of
people who died due to use of aid-in-dying drugs, and the number of those people
who died who were enrolled in hospice or other palliative care programs at the time of
death.
(4) The number of known deaths in California from using aid-in-dying drugs per
10,000 deaths in California.
(5) The number of physicians who wrote prescriptions for aid-in-dying drugs.
(6) Of people who died due to using an aid-in-dying drug, demographic percentages
organized by the following characteristics:
(A) Age at death.
(B) Education level.
(C) Race.
(D) Sex.
(E) Type of insurance, including whether or not they had insurance.
(F) Underlying illness.
1
Assembly Bill x2 15 (Eggman), Chapter 1, Statutes of 2015.
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This report presents data as reported to CDPH from the EOLA-mandated physician
reporting forms received between January 1, 2021 and December 31, 2021, and reflects
information on individuals who were prescribed aid-in-dying drugs and died in the calendar
year of 2021, as well as cumulative counts for the period commencing January 1, 2016. The
information collected has been aggregated to protect the privacy of the individuals.
For the calendar year ending December 31, 2021, 772 individuals received prescriptions
under the Act. In 2021, 486 individuals died following their ingestion of the prescribed aid-in-
dying drug(s), which includes 38 individuals who received prescriptions prior to 2021. Of the
486 individuals, 88.5 percent
2
were 60 years of age or older, 98.6 percent had health
insurance and 91.6 percent were receiving hospice and/or palliative care.
Since the law came into effect June 9, 2016 through December 31, 2021, prescriptions have
been written for a total of 3,766 people under the Act and 2,422 individuals, or 64.3 percent,
have died from ingesting the medications. Of the 2,422 individuals who have died under the
Act, 2,148, or 88.7 percent, were receiving hospice and/or palliative care. Note that
cumulative counts reported above do not match prior reports. These differences arise from
a number of factors including the timing of forms received, the registration of deaths, and
the inclusion of duplicate records in prior reports, which have been removed. A chart
illustrating the number of prescriptions written and deaths under the Act from 2016 through
2021 is provided below in Figure 1.
Figure 1: Summary of EOLA Prescriptions and Deaths 2016-2021
2
Percentages presented in this Data Report are rounded to the nearest tenth. Due to rounding, percentages
when totaled may not equal 100.0 percent.
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Introduction
The EOLA allows an adult diagnosed with a terminal disease, who meets certain
qualifications, to request an aid-in-dying drug from a physician. The Act requires physicians
to use forms specified in statute for submitting information to CDPH. CDPH is responsible
for collecting data from these forms to prepare an annual report. Data presented in this
report are based on the information from physicians’ forms and California death certificates
for calendar year 2021.
More information on the Act, reporting process, and required forms can be found here:
https://www.cdph.ca.gov/Programs/CHSI/Pages/End-of-Life-Option-Act-.aspx.
Participation in the End-of-Life Option Activities
For the calendar year 2021, CDPH received forms from 767 individuals who started the
end-of-life option process, as set forth in the Act, by making two verbal requests to their
physicians at least 15 days apart. A total of 277 physicians prescribed 772 individuals aid-
in-dying drugs. The two most common drug categories prescribed were a combination of a
cardiotonic, opioid, and sedative at 84.2 percent followed by individuals who were only
prescribed a sedative at 0.2 percent. Of the 772 individuals who were prescribed such
drugs, 448 individuals, or 58.0 percent, were reported by their physician to have died
following ingestion of aid-in-dying drugs prescribed under the Act; and 130 individuals, or
16.8 percent, died from the underlying illness or other causes. The ingestion status of the
remaining 194 individuals, or 25.1 percent is unknown. Of the remaining 194 individuals, 88
individuals, or 11.4 percent, have died, but their ingestion status is unknown because follow
up information is not available yet. For the remaining 106 individuals, or 13.7 percent, both
death and ingestion status are pending. Furthermore, 38 individuals with prescriptions
written in prior years ingested and died from the drugs during 2021. As a result, the report
demographics include the 486 individuals who ingested and subsequently died during the
2021 calendar year from aid-in-dying drugs. A chart illustrating the outcomes is provided
below as Figure 2.
In 2021, 486 individuals
3
died from ingestion of aid-in-dying drugs, a rate of 14.8 per 10,000
deaths based on 327,855
4, 5
deaths to California residents in 2021. Excluding COVID-19
deaths, the rate of individuals who died from ingestion of aid-in-dying drugs was 17.3 per
10,000 deaths based on 280,498 non-COVID-19 deaths to California residents in 2021.
3
Total of individuals who received aid-in-dying prescriptions that died in 2021.
4
Calif ornia Department of Public Health, California Comprehensive Death File, created in February 2022.
5
Does not include out-of-state California resident deaths as of February 2022.
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Figure 2: Summary of EOLA Prescriptions Written in Prior Years and Drugs Ingested in
2021
6
Characteristics of Individuals
Of the 486 individuals who died pursuant to EOLA during 2021, 11.5 percent were under 60
years of age, 74.7 percent were 60-89 years of age, and 13.8 percent were 90 years of age
and older. The median age was 76 years. The decedents were 85.6 percent white, 52.3
percent were male; 91.6 percent were receiving hospice and/or palliative care, and 76.7
percent had at least some level of college education. In addition, 87.0 percent informed their
family of their decision to participate in EOLA. A summary of this information is set forth in
Table 1 on pages 9-10 and Table 3 on pages 13-14.
Of the 486 individuals who died pursuant to EOLA during 2021, 66.0 percent were identified
as having had malignant neoplasms (cancer). Neurological diseases such as amyotrophic
lateral sclerosis and Parkinson’s accounted for the second largest underlying illness
grouping, totaling 13.2 percent.
The remaining major categories of underlying illnesses were documented as: cardiovascular
diseases (8.4 percent), respiratory diseases (non-cancer; 6.6 percent), and other diseases
(5.8 percent). The other diseases were documented as: kidney disease (2.1 percent);
endocrine, nutritional and metabolic disease (1.4 percent); immune mediated disease (0.6
6
Based on forms received as of February 1, 2022.
Page 6 of 14
percent); cerebrovascular disease (0.4 percent); and other (1.2 percent). The data are
presented in Figure 3 below.
Certifiers
7
(physicians, coroners, and medical examiners) report the underlying terminal
disease as the cause of death on the death certificates. This approach complies with
applicable law; best ensures the reliability and usefulness of data collected from the death
certificate for state, national, and international surveillance purposes; and effectuates the
California Legislature’s intent to maintain the confidentiality of individuals’ participation in the
Act.
Figure 3: Major Illness Categories for EOLA Individuals in 2021
7
Health and Saf ety Code 102825(a) and Health and Safety code 102860
Page 7 of 14
Among individuals with cancer as the underlying terminal disease – the largest group of
individuals who utilized the Act – lung and bronchus cancer accounted for 12.8 percent,
pancreatic cancer accounted for 11.5 percent, colon cancer accounted for 7.8 percent, both
cancer of the female genital organs and other digestive organs constituted 7.5 percent,
respectively, and both blood and breast cancer comprised of 6.9 percent, respectively. Other
malignant neoplasms accounted for the remaining 39.3 percent, as shown below in Figure 4.
Additional information regarding the other types of malignant neoplasms can be found in
Table 2 on pages 11-12.
Figure 4: Major Malignant Neoplasm Types for EOLA Individuals in 2021
Most of the individuals who participated in the Act had some form of health insurance (98.6
percent). Of those with health insurance, 52.3 percent of individuals had Medicare or
Medicare combined with another type of insurance, while 16.0 percent of individuals had
only private insurance. Individuals who had an unspecified type of insurance comprised
28.6 percent of the Act participants followed by individuals with only Medi-Cal at 1.0
percent, and individuals with other governmental insurance (e.g., Covered California or
Veterans Affairs) at 0.6 percent. 7 individuals, or 1.4 percent, had undetermined health
insurance coverage.
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A physician or trained healthcare professional was present for 209 individuals, or
43.0 percent, at the time of ingestion of the aid-in-dying drug. Of the 209 individuals who
had a physician or trained healthcare professional present at the time of ingestion, another
healthcare provider was present for 46.4 percent of individuals, followed by an attending
physician, who was present for 45.0 percent of individuals. Another physician was present
for 8.6 percent of individuals. The majority, or 93.4 percent, of all individuals were in a
private home for ingestion.
Additional information regarding insurance status and other characteristics of individuals
who died following ingestion of an aid-in-dying drug can be found in Table 3 on pages 13-
14.
Conclusion
This Data Report presents data reported to CDPH from EOLA-mandated physician
reporting forms and reflects information on all patients who were prescribed aid-in-dying
medications in 2021 or prior years, and subsequently died in 2021 of ingesting the
prescribed drugs. The information collected by CDPH has been aggregated to protect the
privacy of the participants.
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Table 1: Demographics of the EOLA Individuals Who Died Following Ingestion of an
Aid-in-Dying Drug
EOLA Individuals
2021
(N=486)
2020
(N=495)
2016-
2019
(N=1441) Total (N=2422)
Age
N (%) N (%) N (%) N (%)
Under 60
56
(11.5) 44
(8.9)
171 (11.9)
271 (11.2)
60
-69
91 (18.7) 111 (22.4)
317 (22.0)
519 (21.4)
70
-79
159
(32.7) 168
(33.9)
427 (29.6)
754 (31.1)
80
-89
113
(23.3) 110
(22.2)
346 (24.0)
569
(23.5)
90 and Over
67
(13.8)
62
(12.5)
180 (12.5)
309
(12.8)
Median Age
(Range)
76 (30-105)
75 (27-107) 75 (23-106) 75 (23-107)
Gender
N (%) N (%) N (%) N (%)
Female
232
(47.7) 252 (50.9) 710 (49.3) 1194 (49.3)
Male
254
(52.3) 243 (49.1) 731 (50.7) 1228 (50.7)
Education
N (%) N (%) N (%) N (%)
No High
School
Diploma
15
(3.1)
10
(2.0)
49 (3.4) 74 (3.1)
HS Diploma or
GED
92
(18.9)
104
(21.0)
291
(20.2)
487
(20.1)
Some College
68
(14.0)
88 (17.8) 264 (18.3) 420 (17.3)
Associate's Degree
37 (7.6) 49 (9.9) 93 (6.5) 179 (7.4)
Bachelor's Degree
134 (27.6) 131 (26.5) 355 (24.6) 620 (25.6)
Master's Degree
88 (18.1) 64 (12.9) 227 (15.8) 379 (15.6)
Doctorate or
Professional
Degree
46 (9.5) 46 (9.3) 151 (10.5) 243 (10.0)
Unknown
6 (1.2) 3 (0.6) 11 (0.8) 20 (0.8)
Page 10 of 14
Table 1: Demographics of the EOLA Individuals Who Died Following Ingestion of an
Aid-in-Dying Drug, continued
EOLA
Individuals
2021 (N=486) 2020 (N=495)
2016-
2019
(N=1441)
Total
(N=2422)
Race/Ethnicity
N (%) N (%) N (%) N (%)
White
416 (85.6) 430 (86.9) 1278 (88.7) 2124
(87.7)
Black
4 (0.8) 6 (1.2) 14 (1.0) 24 (1.0)
American
Indian/Alaska
Native
0 (0.0) 0 (0.0) 1 (0.1) 1 (0.0)
Asian
34 (7.0) 38 (7.7) 81 (5.6) 153 (6.3)
Hawaiian/Pacific
Islander
0 (0.0) 1 (0.2) 3 (0.2) 4 (0.2)
Other
0 (0.0) 1 (0.2) 2 (0.1) 3 (0.1)
Multi
-race 6 (1.2) 2 (0.4) 12 (0.8) 20 (0.8)
Hispanic
25 (5.1) 17 (3.4) 49 (3.4) 91 (3.8)
Unknown
1 (0.2) 0 (0.0) 1 (0.1) 2 (0.1)
Page 11 of 14
Table 2: Underlying Illness of the EOLA Individuals Who Died Following Ingestion of an
Aid-in-Dying Drug
EOLA Individuals
2021 (N=486)
2020 (N=495)
2016-
2019
(N=1441)
Total (N=2422)
Underlying Illness
N (%) N (%) N (%) N (%)
Malignant Neoplasms
(Cancer)
321 (66.0) 344
69.5
1014
70.4 1679 69.3
Lung and Bronchus
41 (12.8) 58 (16.9) 163 (16.1) 262 (15.6)
Pancreas
37 (11.5) 38 (11.0) 94 (9.3) 169 (10.1)
Colon
25 (7.8) 24 (7.0) 71 (7.0) 120 (7.1)
Female Genital Organs
24 (7.5) 22 (6.4) 67 (6.6) 113 (6.7)
Other Digestive Organs
24 (7.5) 25 (7.3) 65 (6.4) 114 (6.8)
Blood
22 (6.9) 19 (5.5) 64 (6.3) 105 (6.3)
Breast
22 (6.9) 20 (5.8) 80 (7.9) 122 (7.3)
Prostate
21 (6.5) 24 (7.0) 84 (8.3) 129 (7.7)
Lip, Oral Cavity, and Pharynx
18 (5.6) 13 (3.8) 43 (4.2) 74 (4.4)
Eye, Brain and Other Parts
of Central Nervous System
17 (5.3) 23 (6.7) 58 (5.7) 98 (5.8)
Mesothelial and Soft Tissue
16 (5.0) 7 (2.0) 17 (1.7) 40 (2.4)
Skin
13 (4.0) 7 (2.0) 29 (2.9) 49 (2.9)
Urinary Tract
13 (4.0) 19 (5.5) 47 (4.6) 79 (4.7)
Ill-defined, Secondary, and
Unspecified Sites
11 (3.4) 18 (5.2) 45 (4.4) 74 (4.4)
Liver
7 (2.2) 16 (4.7) 39 (3.8) 62 (3.7)
Respiratory and Intrathoracic
Organs
4 (1.2) 3 (0.9) 9 (0.9) 16 (1.0)
Thyroid and Other Endocrine
Glands
2 (0.6) 2 (0.6) 9 (0.9) 13 (0.8)
Bone
1 (0.3) 1 (0.3) 7 (0.7) 9 (0.5)
Other Cancers
3 (0.9) 5 (1.5) 23 (2.3) 31 (1.8)
Page 12 of 14
Table 2: Underlying Illness of the EOLA Individuals Who Died Following Ingestion of an
Aid-in-Dying Drug, continued
EOLA Individuals 2021 (N=486)
2020 (N=495)
2016-
2019
(N=1441)
Total
(N=2422)
Underlying Illness N (%) N (%) N (%) N (%)
Neurological Disease 64 (13.2) 56 (11.3) 152 (10.5) 272 (11.2)
Amyotrophic Lateral Sclerosis
31 (48.4) 32 (57.1) 89 (58.6) 152 (55.9)
Parkinson’s Disease 13 (20.3) 8 (14.3) 26 (17.1) 47 (17.3)
Polio 0 (0.0) 0 (0.0) 2 (1.3) 2 (0.7)
Other 20 (31.3) 16 (28.6) 35 (23.0) 71 (26.1)
Cardiovascular Disease 41 (8.4) 27 (5.5) 107 (7.4) 175 (7.2)
Respiratory Disease 32 (6.6) 39 (7.9) 89 (6.2) 160 (6.6)
Chronic Lower Respiratory
Disease
23 (71.9) 31 (79.5) 64 (71.9) 118 (73.8)
Other 9 (28.1) 8 (20.5) 25 (28.1) 42 (26.3)
Kidney Disease 10 (2.1) 7 (1.4) 18 (1.2) 35 (1.4)
Endocrine, Nutritional and
Metabolic Disease
7 (1.4) 8 (1.6) 9 (0.6) 24 (1.0)
Immune Mediated Disease
[e.g., Multiple Sclerosis]
3 (0.6) 2 (0.4) 9 (0.6) 14 (0.6)
Cerebrovascular Disease 2 (0.4) 5 (1.0) 19 (1.3) 26 (1.1)
Other
8
6 (1.2) 7 (1.4) 24 (1.7) 37 (1.5)
8
Includes Gastrointestinal Disease; Liver Disease; Infectious and Parasitic Disease; Musculoskeletal and
Connective Tissue Diseases; Blood Disease
Page 13 of 14
Table 3: Characteristics of the EOLA Individuals Who Died Following Ingestion of an
Aid-in-Dying Drug
EOLA Individuals
2021
(N=
486)
2020
(N=
495)
2016-
2019
(N=1441)
Total (N=2422)
Insurance
N (%) N (%) N (%) N (%)
Med
icare or Medicare with
another type of insurance
254 (52.3) 301 (60.8) 903 (62.7) 1458 (60.2)
Private
Insurance
78 (16.0) 70 (14.1) 214 (14.9) 362 (14.9)
Medi
-Cal
5 (1.0) 9 (1.8) 35 (2.4) 49 (2.0)
Other
Governmental Insurance
3 (0.6) 3 (0.6) 6 (0.4) 12 (0.5)
Has Insurance, but unknown
type
139 (28.6) 57 (11.5) 185 (12.8) 381 (15.7)
No Insurance
0 (0.0) 0 (0.0) 6 (0.4) 6 (0.2)
Unknown
7 (1.4) 55 (11.1) 92 (6.4) 154 (6.4)
Hospice and/or Palliative Care
N (%) N (%) N (%) N (%)
Enrolled
445 (91.6) 433 (87.5) 1270 (88.1) 2148 (88.7)
Not Enrolled
39 (8.0) 52 (10.5) 129 (9.0) 220 (9.1)
Unknown
2 (0.4) 10 (2.0) 42 (2.9) 54 (2.2)
Aid-in-Dying Drugs
N (%) N (%) N (%) N (%)
Cardiotonic, Opioid, Sedative
409 (84.2) 419 (84.6) 687 (47.7) 1515 (62.6)
Sedative
1 (0.2) 3 (0.6) 518 (35.9) 522 (21.6)
Other
27 (5.6) 32 (6.5) 88 (6.1) 147 (6.1)
Unknown
49 (10.1) 41 (8.3) 148 (10.3) 238 (9.8)
Patient Informed Family of
Decision
N (%) N (%) N (%) N (%)
Yes
423 (87.0) 424 (85.7) 1242 (86.2) 2089 (86.3)
No
4 (0.8) 8 (1.6) 36 (2.5) 48 (2.0)
No Family to Inform
8 (1.6) 10 (2.0) 27 (1.9) 45 (1.9)
Unknown
51 (10.5) 53 (10.7) 136 (9.4) 240 (9.9)
Page 14 of 14
Table 3: Characteristics of the EOLA Individuals Who Died Following Ingestion of an
Aid-in-Dying Drug, continued
EOLA Individuals
2021 (N=486)
2020 (N=495)
2016-
2019
(N=1441)
Total
(N=2422)
Physician or Trained
Healthcare Provider Present at
Ingestion
N (%) N (%) N (%) N (%)
Yes
209 (43.0) 182 (36.8) 602 (41.8) 993 (41.0)
Attending Physician
94 (45.0) 81 (44.5) 385 (64.0) 560 (56.4)
Other Physician
18 (8.6) 18 (9.9) 39 (6.5) 75 (7.6)
Other Healthcare
Provider
97 (46.4) 83 (45.6) 178 (29.6) 358 (36.1)
No
29 (6.0) 36 (7.3) 159 (11.0) 224 (9.2)
Unknown
248 (51.0) 277 (56.0) 680 (47.2) 1205 (49.8)
Location Where Aid
-in-Dying
Drugs were Ingested
N (%) N (%) N (%) N (%)
Private Home
454 (93.4) 454 (91.7) 1299 (90.1) 2207 (91.1)
Assisted
-Living Residence
16 (3.3) 15 (3.0) 75 (5.2) 106 (4.4)
Nursing Home
4 (0.8) 19 (3.8) 38 (2.6) 61 (2.5)
In
-patient Hospice Residence
10 (2.1) 3 (0.6) 21 (1.5) 34 (1.4)
Acute Care Hospital
0 (0.0) 2 (0.4) 2 (0.1) 4 (0.2)
Other
2 (0.4) 2 (0.4) 6 (0.4) 10 (0.4)
