Applying for Medical Aid in Dying: The MAiD process at Denver Healt
In July 2024, I interviewed Katie Sue Van Valkenburg, the Program Coordinator for Medical Aid in Dying (MAiD) for Denver Health to learn more about MAiD, how it is provided in Colorado, how Denver Health supports MAiD patients, and what are some of the common challenges for patients and their families pursuing MAiD. This is the second of four blogs from that interview, which has been edited and condensed for clarity.
GDM: So, tell me a little bit about your role at Denver Health and what the Denver Health program looks like.
Katie Sue: We’re really cool- I absolutely love our program. Denver Health has been incredible in supporting us in accessing medical aid in dying and making it accessible to the whole community, not just established Denver Health patients.
Our program was founded by Skye O’Neill, Dr. Dan Handel, and Dr. Jeremy Long back when the law was passed in 2016. We were up and running almost immediately, which is great. To my knowledge, we are one of the only centralized programs in the country that has this very specific nook of specialized MAiD providers and MAiD specific care.
What Denver Health offers is everything related to the law. We provide the 2 doctors/nurse practitioners, the paperwork, the education, the medication itself, and also the physical and emotional support for the patient and their next of kin through the entire journey through bereavement. Our role does not end when somebody passes, it continues as long as somebody needs us.
The DH MAiD program very small but mighty. We are one of the largest prescribers of MAiD in the state, but it is just 2 staff. It's our Medical Director, Dr. Kerri Mason, who splits her time between the emergency room and MAiD - she definitely serves a wide spectrum of patients! She has been so wonderful. Dr. Mason is the attending physician for almost every single patient our program sees. It's beautiful to see a doctor have such compassionate care and have a genuine human interaction with people. People are very often surprised to hear that she gives out her personal cell phone number, that's very rare these days.
The other staff member is me! I am a social worker by trade, but my title is Program Coordinator. I do everything related to the paperwork, helping patients, doing the intake, and I offer all of the bereavement and emotional support throughout the process.
Those are the 2 staff and then we have a group of 14 consultant physicians- the providers who see the patients for their second visit. Incredibly, they all volunteer. They are all giving up a portion of their time to see these patients.
And the way that we've structured our program is really lovely. All of our patients are seen on Tuesdays for their first visits. Dr. Mason and I see new patients on Tuesdays, and then we see patients again on the 8th day to allow the full 7-day waiting period to pass. We always schedule out our consultant physicians ahead of time. This is so the volunteer consulting physicians know that they’re “on the clock” for about two and a half hours - three hours. Dr. Mason and I attend both first visits and second visits with patients.
While all our consultants are dedicated to MAiD, each one of them has a different role at Denver Health and it's pretty unique to see them in this MAiD role. Two of them are pediatric doctors, so they're always laughing like “this is so different from the little buddies we see day to day.” We have an infectious disease doctor. We have a surgeon. All of them are just so dedicated to making sure that people feel supported in their end-of-life goal.
One of the best parts of our program is that a patient does not have to be an established patient of Denver Health. That means anybody who lives in the state of Colorado can call and say, “We think that we meet the qualifications. What are the next steps?” I usually do about a 30-minute to an hour-long consultation. It's a full bio-psycho-social assessment where I learn all about who they are, their disease, but also what treatments have they done? What concerns do they have? Are they financially secure? Are they food secure? Who's their next of kin? Are they on hospice? I look at all of the factors because MAiD is an informed decision. We don't want to be accessing MAiD because we're worried about paying next month's rent. And that is a very real situation that happens for people. So, it gives me the chance to connect them with appropriate community resources before we start MAiD so that they feel like they have all the tools in their toolbox.
Once we have that initial intake, if they're qualified, we create a medical record number, and we go to set up their appointments and get all the necessary documents. If they're not qualified, meaning that either they have a chronic illness or a terminal illness, but they don't have 6 months or less to live, or they don't necessarily have a physical illness, but they have a very debilitating chronic mental health illness, I do suicide assessments. I do safety assessments. I connect them with resources, if needed. I do welfare checks to make sure that they're safe. Typically, free of charge. We don't ask for money for any of this, but we'll get them connected and complete a warm hand them off to somebody who makes sure that they are safe, and that they have the resources they need going forward. So, no one calls us and gets nothing in return. We're always going to make sure they have some foundation to go back to for safety.
Once a patient is established, we have the first appointment. If they're eligible, we get the documents and all we need for Denver Health. They have to show that they're a resident of Colorado. Our favorite proof for this is a Colorado Driver's License because that's a guarantee that you're a resident here. We can also take tax documents, or a mortgage, or a leasing agreement, or the nursing home contract wherever they live.
The other documents we need are those related to their medical care. For most of our patients, they're on hospice, so we ask for a Certificate of Terminal Illness (CTI), and that's a document required by Medicare created by hospice. It's something that they have to submit to Medicare, signed by their doctor, once somebody comes onto care with a hospice. So that is a really good way for us to see - why hospice, why now, what do diagnosis they have? What treatment have they done? And the fact that a medical doctor is signed off that they have 6 months or less to live - that's important. But we can also accept documents from their oncologist or palliative care doctor because some of them might be doing palliative chemo and are not on hospice yet, and that's okay. But then we just ask for a few extra documents to make sure we have a good picture of them.
And that's how we operate. So not too much paperwork on their end. It's a lot of me nagging doctors, but we try to make it as easy as possible for our patients.
GDM: After they have the second meeting, then the prescription is given them?
Katie Sue: The way that we operate is that they have their 1st visit, and then within those 7 days they sign the written request form, submit it back to me, and on the day of the second visit, they have the meeting with Dr. Mason and the consulting doctor, and should the doctors agree that the person is eligible, the script is written that day. I would say it's a fairly even mix of people that have the script ready that day for pickup, and people that leave it there at the pharmacy for an undisclosed amount of time. But if they want it, they can pick it up, and we have seen anecdotally in the last few months, a lot more people wanting it ready that day so that they can take it that same day. We are seeing a lot of humans that were ready before they even talked to us. So, by the time 7 days is over, they are more than ready to bow out.
Most of our patients pick up their medications from the Denver Health discharge pharmacy. We have 2 incredible pharmacists who have been devoted to supporting MAiD patients. They very much babysit those prescriptions to make sure that they're done correctly and safely. The bonus to using Denver Health’s pharmacy is that our pharmacists can release the medications the same day, which is not something readily available elsewhere.
Denver Health does require 48 hours heads up if they want to pick it up the same day. So, say that their second appointment is on Wednesday - if they call on Monday (before their appointment), the pharmacist will compound it, because it does take a little bit of time to pull all that together, and then they can pick it up at the Denver Health discharge. The pharmacy knows to not release the medications until they see the notes from the doctors, saying that the person completed and was approved for the process. So, there are some checks and balances to make sure we're not just handing out medication before the second visit.
To my knowledge, we're the most cost-effective out-of-pocket program. Our prices are likely to increase just because of the growing need and the growing support that we're going to need to offer, but right now, the total cost is $695 - the 1st visit is $125, the second visit is $250, and the meds are $320 - so all in all not too bad. I find most of our demographics are fairly affluent, white folks who have no problem covering those costs, but, as many people know, Denver Health serves a large, diverse community. So, some of our patients really can't afford those costs.
So, we do have financial assistance available, we can cover the entire process. So, the appointments, and the meds, or we can cover just part of it, if a patient needs that support. I think it's important to say that they exist, and then ours is just for Denver Health patients to make sure that, if they're coming to us, if they need it, they shouldn't have to worry about the financial aspect.
Next week, part 3 of our interview will focus on the dying process with MAiD.
