Ramona Chiya, suffering from stage 4 lung cancer, was at home in her Waikiki apartment Monday when she drank from a glass of pineapple-mint Shaka Tea mixed with lethal drugs prescribed to her under Hawaii’s Our Care, Our Choice Act, which allows medical assistance in dying for terminally ill patients.

The liquid had a bitter taste, according to Chiya’s daughter, Lesa Griffith, who said the medication came in powdered form to mix with 3 ounces of water or apple juice. The instructions suggested a taste-test by dipping a toothpick into the concoction and adding sweetener if needed.

Griffith said she was surprised her frail mother managed to swallow most of the milky liquid.

Chiya, 78, quickly fell into a deep sleep and died within 15 minutes, according to Griffith, who was at her bedside along with her brother and aunt.

A former textile designer, Chiya initially resisted the idea of ending her life under the Our Care, Our Choice Act, which went into effect in 2019, after getting her terminal prognosis in September 2020. She told the Honolulu Star-Advertiser in August that she discussed it with her oncologist but decided it wasn’t for her.

At that time, she had already outlived her initial prognosis and had stopped traditional cancer treatments in favor of alternative therapies. But as her health declined and she struggled to breathe, Chiya had a change of heart.

“She loved her room, she loved her bed, she loved her favorite painting (a stylized portrait of a woman) and looking out the window,” Griffith said. “Until the end she said that as long as she was waking up and enjoying seeing the sun through her window and enjoying her painting, she was happy to be here.

“Then one day she woke up and said she felt she did not want to be here. She said, ‘People are right — you know when it’s time.”

An estimated 70 patients completed the medical-aid-in-dying request process last year, nearly double the number in 2020, when 37 patients qualified, according to state Department of Health testimony submitted to the Legislature during its most recent session. Complete data for 2021 was not immediately available, but DOH said 32 of the 37 patients in 2020 ingested the life-ending medication, causing their death.

Most of the patients who qualified cited some form of cancer as their primary underlying illness.

Aside from a terminal prognosis of six months or less, safeguards established under the law mandate that patients must be mentally capable of making an informed decision and able to take the prescribed medication themselves.

They are required to make two separate verbal requests to an attending physician not less than 20 days apart — the longest waiting period among the 10 states with similar laws — and also must see a consulting physician and a counselor, such as a psychiatrist, psychologist or licensed clinical social worker. Once deemed eligible by the three providers, the patient may submit a written request for medication.

A final attestation form must be completed 48 hours before the medication is ingested.

Supporters of medical-aid-in-dying say the rules are too cumbersome and that many patients die before completing the process. Contributing to any delays is a shortage of participating attending physicians — only 14 participated in such cases in 2020, including just one on Hawaii island, two on Maui and none on Kauai, according to DOH’s annual report on the Our Care, Our Choice program.

On average, it took 45 days for patients to complete the eligibility process, from the first oral request to the date of prescription, and for at least one patient, the process took more than five months, the report said.

Bills that would have authorized other health care professionals, including advanced practice registered nurses and licensed psychiatric mental health nurse practitioners, to provide the required consultations and counseling did not survive the 2022 legislative session.

The measures also proposed shortening the mandatory waiting period between oral requests to 15 days and waiving the waiting period for patients who are not expected to live that long.

In its legislative testimony, DOH noted that it doesn’t track the number of patients who die prior to completing all the steps; however, anecdotal input from health care providers has been “very consistent” that “patients in rural communities struggle to find a participating provider” and that “patients with grave health prognoses expire during the waiting period, often with tremendous suffering.”

Among the groups submitting testimony in support of the changes were professional organizations representing nurses, clinical oncology physicians, marriage and family therapists, and psychologists, along with Hawai‘i Pacific Health.

A smaller number of opponents included the Hawaii Family Forum and the Hawai‘i Psychiatric Medical Association, which expressed concern for what they said would be a loosening of safeguards that protect frail elders and other vulnerable patients.

IN CHIYA’S case, she decided to restart the process in December or January, recalled Griffith. It took several weeks to get an appointment for a psychiatric assessment, which was scheduled for Feb. 10, and after satisfying the requirements, she was notified March 14 that a prescription had been issued.

They paid a little more than $400 for the lethal drugs, prepared by a special compound pharmacy, because it wasn’t covered by Chiya’s health insurance.

“We picked up the medication and it sat on a shelf,” Griffith said. “We didn’t really talk about it much until she began experiencing increasing shortness of breath. Then one day she said to me, ‘You know how I said I didn’t want to suffer? I’m starting to suffer.’”

Even then there was little further conversation on the subject, and Chiya remained engaged in her life for as long as she could, according to Griffith.

“Mom never gave up. Even after purchasing the medication she kept up her regimen of natural treatments and continued life as normal, asking her daughter-in-law for a new bottle of her favorite perfume (L’Air du Temps), placing new orders for supplements, making dinner requests to sate her cravings even as her appetite waned,” she said.

Then on June 11, when Griffith’s brother arrived from Dubai for a visit, Chiya unexpectedly told her children to make a timeline for administering the medication the next day.

The protocol calls for anti-nausea pills to be taken an hour beforehand. When ready, 3 ounces of a clear liquid are poured into an amber glass bottle containing the lethal powder, and the bottle is tightly closed and the mixture shaken until reaching a milky consistency. The entire contents must be ingested within one to two minutes.

Drowsiness sets in within two to 40 minutes, followed by a deep sleep and loss of consciousness that progresses to a coma as breathing slows and often becomes irregular, the instructions advised. Death occurs within eight minutes to 30 hours.

Griffith said they told their mother it felt “too rushed” and to wait another day, until Monday, when they could properly prepare. She said they didn’t try to talk Chiya out of her decision.

“My mom has always known her own mind,” Griffith said.

By then Chiya had stopped eating and was so weak, her daughter said that if they had waited any longer she might not have been able to ingest the medication on her own, a requirement of the law.

On Monday, she returned calls and text messages to the few family members and friends who were aware of her plans. An hour after taking the anti-nausea pills, at 3:52 p.m., Chiya, sitting on the edge of her bed, picked up the glass containing the milky mixture.

“She drank quite a lot of it in one slug,” Griffith said. “She left a little bit at the bottom and reacted so quickly.”

Griffith and her brother laid their mother down and watched and waited as she took her last breaths. Griffith said she was so focused on following the precise timeline that she wasn’t able to immediately process what had just passed.

“She went quickly and peacefully,” she said.

As arranged, nurses from Islands Hospice arrived just as Chiya died, made an assessment, called in the time of death and bathed her.

“I’m grateful for this option that allowed us to give Mom the peaceful death at home that she wanted. She knew when it was time,” Griffith said.

She said she agreed to share the story of her mother’s death “to lift the veil on something I think is still not well-known as an option here.”

“She helped a lot of people in a lot of different ways in her life, so if my mom’s choice can help other people in the future, it carries on her legacy.”