End of Life Medication in California: Eligibility, Requests, and Cost

End-of-life medication in California is a lethal, self-administered oral drug cocktail prescribed under the state’s End of Life Option Act. The most common prescription is a four-drug powder, known as DDMA, that combines digoxin, diazepam, morphine sulfate, and amitriptyline. The patient mixes the powder into a few ounces of liquid and drinks it. California law does not dictate which drugs a physician must prescribe, but this combination accounts for the overwhelming majority of prescriptions reported to state health officials.¹

What Is in the Prescription

The standard DDMA protocol is compounded by a pharmacy into a powder, packed into a glass bottle, and typically contains:

Digoxin 100 mg, a cardiac glycoside that stops the heart
Diazepam 1 g, a sedative that induces deep unconsciousness
Morphine sulfate 15 g, an opioid that suppresses breathing
Amitriptyline 8 g, an antidepressant with strong sedating effects at high doses

Some physicians prescribe a five-drug variant that adds phenobarbital. State data from recent years shows that a combination of a cardiotonic, opioid, and sedative was by far the most common prescription category.² An older option, secobarbital (brand name Seconal), was once standard but became prohibitively expensive after a 2015 price spike pushed costs above $3,000 per dose. Compounded cocktails are now the norm and bring the medication cost down to around $700, plus delivery fees.

About an hour before the lethal dose, patients typically take anti-nausea medications, commonly metoclopramide and sometimes haloperidol, to prevent vomiting and keep the full dose down.

How the Medication Is Taken and What Happens

California law requires self-administration. The patient must perform the final act of ingesting the drug themselves. Another person may help prepare the mixture, but no one else can put the drug in your mouth or push it through a tube. The medication can be taken by mouth, through a PEG feeding tube, or through a rectal tube.³ Patients taking it orally need to be able to swallow roughly four to six ounces of liquid.

The medication works quickly. Based on clinical reporting data from Oregon’s longer-running program, the median time from ingestion to unconsciousness is about five minutes, with a range of one to 45 minutes. Median time from ingestion to death is roughly 50 minutes, and the range runs from as few as six minutes to, in rare cases, around 24 hours.⁴ The patient falls into a deep sleep first and does not experience the dying process consciously.

Who Qualifies in California

Every one of the following requirements must be met. To qualify, a person must:

Be at least 18 years old and a California resident
Have a terminal illness with a life expectancy of six months or less, confirmed by two physicians
Be mentally capable of making their own healthcare decisions, including understanding the diagnosis, prognosis, risks, and alternatives
Be physically able to self-administer the medication
Make the request voluntarily, free of coercion or pressure

Age or disability alone never qualifies someone. No one can request the medication on another person’s behalf. A healthcare agent, family member, or power of attorney cannot make the request even if the patient previously expressed a desire for it, and the Act cannot be used through an advance directive.⁵

How to Request the Prescription

The End of Life Option Act is codified at California Health and Safety Code Sections 443 through 443.22. It first took effect on June 9, 2016, and SB 380, effective January 1, 2022, shortened the waiting period between oral requests from 15 days to 48 hours.

Two Oral Requests and One Written Request

The patient must make two separate oral requests to their attending physician, spaced at least 48 hours apart. The patient must also submit one written request on a specific form, signed by the patient and two witnesses.⁶

Two Physician Evaluations

Two physicians must independently evaluate the patient. The attending physician confirms the terminal diagnosis, discusses the prognosis, and reviews all alternatives including hospice care, palliative care, and pain management. A separate consulting physician then independently confirms the diagnosis, prognosis, and the patient’s mental capacity. If either physician suspects a mental health condition is impairing judgment, they must refer the patient to a psychiatrist or psychologist, and no prescription can be written until that evaluation clears the patient.⁵

Picking Up the Medication

Once the attending physician writes the prescription, the patient or a designated person picks it up from a compounding pharmacy. The pharmacist explains storage and handling: the drug should be kept in a secure, locked location, and any unused portion must be disposed of safely following the pharmacist’s instructions.³ Getting the prescription does not obligate anyone to use it. Many people who obtain the medication never take it, finding comfort simply in knowing the option exists. A patient can withdraw a request at any time, including after the prescription is filled.⁷

If a Patient Loses Decision-Making Capacity

If the patient loses the mental capacity to make medical decisions before completing the request process or before ingesting the medication, the process stops. A family member cannot step in to complete the request or administer the drug. The law requires the patient to be mentally capable at every stage, from the initial request through the moment they choose to ingest the medication. For patients with conditions that may affect cognition, starting the request process early is critical.

Cost and Insurance Coverage

The compounded medication typically costs around $700, plus delivery fees. On top of that, patients should expect fees for the required physician consultations, which vary by provider. Many compounding pharmacies operate on a cash-only basis.

Insurance coverage is mixed. Some private insurers cover the medication and physician visits; others do not. Medi-Cal may cover some or all of the costs, but patients should check with their plan directly. Federal law sets a hard limit: under the Assisted Suicide Funding Restriction Act of 1997, no federal health care funds, including Medicare and the federal share of Medicaid, can pay for items or services intended to cause death.⁸ Any Medi-Cal coverage of these costs therefore comes from state dollars only.

Death Certificate and Life Insurance

A death resulting from ingesting the prescribed medication is not classified as suicide under California law. The death certificate lists the underlying terminal illness as the cause of death, not the medication.⁵ Because the death is not legally considered suicide, standard suicide exclusion clauses in life insurance policies should not apply.

If Your Doctor Won’t Participate

Participation is entirely voluntary for healthcare providers. A physician, pharmacist, or health system that objects on grounds of conscience, morality, or ethics is not required to take any action in support of a patient’s decision, is not required to inform the patient of their rights under the Act, and is not required to refer the patient to a willing provider.⁷

If your physician or health system opts out, you will need to find a participating provider on your own. Organizations such as Compassion & Choices maintain directories of willing physicians, and some hospital systems publicly state whether they participate. Requesting a copy of your medical records is a practical first step so you can consult with another physician, even though the law does not require your current doctor to facilitate that transfer.

1
California Department of Public Health (CDPH). California End of Life Option Act 2024 Data Report
2
California Department of Public Health. California End of Life Option Act 2020 Data Report
3
UC San Diego Health. Physician Aid in Dying
4
Stanford Health Care. The End of Life Option Act at Stanford Health Care
5
UCLA Health. California End of Life Option Act (EOLOA)
6
California Department of Public Health (CDPH). End of Life Option Act
7
Physician Assistant Board. California End of Life Option Act
8
Office of the Law Revision Counsel. 42 U.S. Code 14402 – Restriction on Use of Federal Funds Under Health Care Programs