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

The end-of-life medication used in California is a lethal prescription drug combination available under the state’s End of Life Option Act. The most common protocol, known as DDMA, mixes four drugs into a powder that the patient dissolves in liquid and drinks: digoxin to stop the heart, diazepam to induce deep sleep, morphine to suppress breathing, and amitriptyline for added sedation. California law does not name a required drug, but this four-drug cocktail accounts for the overwhelming majority of prescriptions. In 2024, 1,591 people received prescriptions under the Act and 1,032 died after ingesting the medication.¹

What’s in the Prescription

The prescribing physician chooses the drugs, and in practice almost all prescriptions follow one of a few established recipes. State data shows that a combination of a cardiotonic, an opioid, and a sedative was by far the most common category.² The standard DDMA protocol 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. Either way, a compounding pharmacy prepares the drugs as a powder packed into a glass bottle. The patient mixes the powder with a small amount of liquid and drinks it. Roughly an hour before, patients take anti-nausea drugs, commonly metoclopramide and sometimes haloperidol, to help keep the full dose down.

An older option, secobarbital sold as Seconal, was once the standard prescription. After a 2015 price spike pushed costs above $3,000 per dose, compounded cocktails largely replaced it.

What Happens After You Take It

The medication works quickly. Clinical reporting from Oregon’s longer-running program shows a median time from ingestion to unconsciousness of about five minutes, with a range of one to 45 minutes. The median time from ingestion to death is around 50 minutes, though it can be as short as six minutes or, rarely, as long as roughly 24 hours.³ The patient falls into a deep sleep first and does not experience the dying process consciously.

California law requires self-administration. The patient has to ingest the medication themselves. Another person can 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.⁴ Patients taking it orally need to be able to swallow roughly four to six ounces of liquid.

Because a death under the Act is not classified as suicide, the death certificate lists the underlying terminal illness as the cause of death, not the medication.⁵ Standard suicide exclusion clauses in life insurance policies should not apply for the same reason.

Who Qualifies

The eligibility requirements are strict, and every one of them has to 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.
Be physically able to self-administer the medication.
Make the request voluntarily, without coercion.

No one can request the medication on someone else’s behalf. A healthcare agent, family member, or power of attorney cannot make the request even if the patient previously said they wanted it, and the law cannot be used through an advance directive.⁵ Age or disability alone never qualifies someone. A terminal diagnosis with a six-month prognosis is always required.

How You Request the Medication

Getting the prescription involves a set sequence of requests and evaluations, found in California Health and Safety Code Sections 443 through 443.22.⁶

Two Oral Requests and One Written Request

The patient makes two separate oral requests to the attending physician, spaced at least 48 hours apart. That waiting period used to be 15 days before SB 380 took effect on January 1, 2022. The patient also submits one written request on a specific form, signed by the patient and two witnesses.

Two Physician Evaluations

The attending physician confirms the terminal diagnosis, discusses the prognosis, and reviews all alternatives including hospice, palliative care, and pain management. A separate consulting physician independently confirms the diagnosis, prognosis, and 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 Prescription

Once the attending physician writes the prescription, the patient or a designated person picks it up from a pharmacy. The pharmacist reviews storage and handling. The medication should be kept in a secure, locked location, and any unused portion has to be disposed of safely.⁴ Getting the prescription does not obligate anyone to use it. Many people who obtain the medication never take it, finding comfort in knowing the option is there.

A patient can withdraw the request at any point, including after receiving the prescription. Coercing someone into requesting the medication, destroying a written withdrawal, or administering the drug to someone without their knowledge is a felony.⁷

Cost and Insurance

The medication itself typically costs around $700 from a compounding pharmacy, plus delivery fees. That is well below the $3,000-plus that secobarbital cost after its 2015 price spike. Physician visit fees for the required consultations are separate and vary by provider.

Insurance coverage is uneven. Some private insurers pay for the medication and physician visits; others do not. Medi-Cal may cover some or all of the cost, but coverage varies and patients should check directly with their plan. Federal law draws a hard line here: 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 Where Medi-Cal does cover these costs, the money comes from state dollars only. Many compounding pharmacies operate on a cash basis regardless of insurance.

If You Lose Decision-Making Capacity

The law requires mental capacity at every stage, from the first request through the moment of ingestion. If a patient loses the capacity to make medical decisions before completing the request process or before drinking the medication, the process stops. A family member cannot step in to complete the request or administer the drug. For patients with conditions that may affect cognition as they progress, starting the process early matters.

If Your Doctor Won’t Participate

Participation in the Act 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 to support a patient’s decision, and that includes no obligation to inform the patient of their rights under the Act and no obligation to refer to a willing provider.⁷

In practice, patients whose physician or health system opts out often have to find a participating provider on their own. Organizations like Compassion & Choices keep directories of willing physicians, and some hospital systems publicly state whether they participate. Requesting a copy of your medical records so you can consult with another physician is a practical first step, even though your current doctor is not required to help arrange the 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
Stanford Health Care. The End of Life Option Act at Stanford Health Care
4
UC San Diego Health. Physician Aid in Dying
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