Who will be the doctors of death in a time of assisted suicide?

October 11, 2017 by Craig Goldie, The Conversation
Gloria Taylor is assisted into British Columbia Supreme Court in Vancouver, B.C., on December 1, 2011. Taylor, who has Lou Gehrig’s disease, was the first person in Canada to win the right to die with help of a doctor. Credit: THE CANADIAN PRESS/Darryl Dyck

Medical assistance in dying (MAID) became a reality in Canada when legislation was passed in July 2016. This is the hastening of death through a lethal dose of medication —either by self-ingestion (assisted suicide) or physician injection (euthanasia).

More than 2,000 Canadians have received MAID, administered by a number of physicians. Few of those doctors are palliative care specialists, who are purposely keeping their distance from MAID to avoid further stigmatization as the physicians of death. They do not want to be associated with treatment failure, or viewed as only providing care to those who have either given up or been deemed hopeless.

This has left MAID without leadership or co-ordination, leading to unequal access and confusion among the public and health-care providers.

I am a palliative care physician at Queen's University who teaches medical students, residents and other health-care providers. I am adjusting to the new reality of palliative care in the MAID era. Many and families ask me about it and a fair number receive it. One patient asked me to be there for his MAID death.

I speak to nursing and physician groups and at public events where I can be simultaneously applauded and criticized for not providing doctor-assisted suicide as part of my palliative care. At these events, there is always uncertainty about MAID: the ethics, legalities, practicalities (how, where, by whom). And there are questions about the comfort of health-care providers with an intervention aiming to administer death rather than stave it off.

Doctors who improve quality of life

To understand why palliative care does not wish to "own" MAID requires an understanding of the meaning of palliative care.

Palliative care is an approach that improves the quality of life of patients and their families facing a life-threatening illness by preventing and relieving suffering through treatment of pain and other problems —physical, psychosocial and spiritual. It is often provided alongside disease-focused treatments like chemotherapy, radiation or surgery.

Traditionally, palliative care has mostly provided care to patients with cancer, but it is appropriate for anybody with advanced diseases of organs like the heart, lung, kidneys and liver. And for those with nervous system disorders like ALS or dementia. Palliative care is also provided to children with the above illnesses and also those with congenital disorders.

Research shows that palliative care can improve symptom control, quality of life and, in some cases, lead to improved survival. But palliative care is still often seen as the care provided "when nothing else can be done" and when someone is close to death.

This causes problems where patients don't want to see palliative care "too early" and their doctors are reluctant to refer for similar reasons. This shrinks the time in which doctors can help with symptoms and care plans for the future. A large cancer centre in the U.S. noted this problem and changed the name of their "palliative care" team to "supportive care."

There was an immediate 41 per cent increase in referrals and those referrals came earlier due to less stigma around the name.

Reducing suffering, not stopping life

Admittedly, palliative care and MAID are both trying to treat suffering, but the methods are different: palliative care does not try to speed up (or slow down) death whereas MAID expressly speeds up death. Palliative care tries to reduce suffering by treating physical, psychosocial and spiritual distress whereas MAID stops suffering by stopping life.

Before MAID was legalized, patients whose suffering couldn't be fixed by other means would get to reduce their awareness and suffering until they died.

While most palliative care doctors don't provide MAID, we're not all opposed to its legalization. I support a person's choice to hasten their death if they have "grievous and irremediable" suffering, which is the terminology used in the Supreme Court decision. There are some patients that, despite our best interventions, still suffer a bad . Many more patients never get the "best" intervention as they can't access expert palliative care where they live or the system is too overburdened to provide care.

Who will be the doctors of death?

So who should have responsibility for MAID? There are no "specialists" that reliably provide MAID, and many doctors struggle to manage the requests of patients. The few doctors who provide it are generally doing it on top of their regular work, risking burnout.

A new group —the Canadian Association of MAID Assessors and Providers —provides peer support and clinical guidelines. They are also trying to keep up with a legal landscape that is changing frequently, especially around the "reasonably forseeable" death clause which was included in the legislation but has not been defined and thus is subject to varying interpretation.

They are also expecting legal challenges regarding "mature minors" and patients with advanced directives who are not able to request MAID, such as those with advanced dementia. Currently only adults who are mentally competent to consent at the time of the MAID procedure are eligible to receive it. Nobody can ask for MAID in a living will or have their loved ones request it on their behalf.

In the end, palliative care , providers of MAID and the public all have the same goal: to alleviate suffering, to maximize quality of life and to respect autonomy for those suffering from life-limiting illnesses.

Almost everyone agrees that palliative care needs to be strengthened in Canada with more education, capacity and funding. Better will mean less suffering for patients. For those who request MAID due to their suffering, they should be able to access it in an equitable, respectful and expedient way.

End-of-life care remains an uncomfortable but critically important topic and is really the responsibility of everyone.

Explore further: Canada's largest hospital reports on year of medically assisted dying

Related Stories

Canada's largest hospital reports on year of medically assisted dying

May 24, 2017
Today, in the New England Journal of Medicine, the team from University Health Network in Toronto that developed the organization's protocol for medical assistance in dying (MAiD) describes UHN's approach and experience. ...

Study examines palliative care trends in patients with end-stage liver disease

June 29, 2017
A new study has uncovered low rates of referral for palliative care in US patients with end-stage liver disease, although rates have been slowly increasing over time. The Hepatology study also found that certain socioeconomic ...

Misunderstanding of palliative care leads to preventable suffering

December 13, 2013
A new review says palliative care's association with end of life has created an "identity problem" that means the majority of patients facing a serious illness do not benefit from treatment of the physical and psychological ...

Palliative care improves quality of life, lessens symptoms

November 22, 2016
People living with serious illness who receive palliative care have better quality of life and fewer symptoms than those who don't receive palliative care, according to a new study by researchers at the University of Pittsburgh ...

Palliative care may mean fewer difficult transitions for older adults nearing end of life

November 18, 2016
Palliative care is treatment—such as medication, nutritional support, or massage—that helps you feel better when you have a serious illness. Palliative care can help ease pain, insomnia, shortness of breath, nausea, and ...

Major changes needed to improve palliative care in Canada

August 22, 2016
Canada's approach to palliative care must be broadened to offer support to people with serious chronic illnesses other than cancer, states an analysis in CMAJ (Canadian Medical Association Journal).

Recommended for you

Eating iron-fortified grain improves students' attention, memory

July 18, 2018
Adolescent students in a rural school in India who consumed an iron-biofortified version of the grain pearl millet exhibited improved attention and memory compared to those who consumed conventional pearl millet, according ...

Lowering hospitals' Medicare costs proves difficult

July 18, 2018
A payment system that provides financial incentives for hospitals that reduce health-care costs for Medicare patients did not lower costs as intended, according to a new study led by Washington University School of Medicine ...

Vaping tied to blood clots—in mice

July 18, 2018
A new study involving mice raises another concern about the danger of e-cigarettes in humans after experiments showed that short-term exposure to the device's vapors appeared to increase the risk of clot formation.

People who tan in gyms tan more often, and more addictively, than others, new research shows

July 18, 2018
Gyms are places people go to get healthier. But nearly half the gyms in the U.S. contain a potentially addictive carcinogen—tanning beds, report UConn researchers in the July 18 issue of JAMA Dermatology.

Omega 3 supplements have little or no heart or vascular health benefit: review

July 17, 2018
New evidence published today shows there is little or no effect of omega 3 supplements on our risk of experiencing heart disease, stroke or death.

Study shows that people most affected by alcohol also most impacted by sleep deprivation

July 17, 2018
A team of researchers from the German Aerospace Center and Forschungszentrum Jülich has found that people who are most susceptible to alcohol intoxication are also most susceptible to cognitive problems due to sleep deprivation. ...

1 comment

Adjust slider to filter visible comments by rank

Display comments: newest first

jhnycmltly
not rated yet Oct 11, 2017
Bloodletting until you are dead is safe and not uncomfortable at all. Just saying.

Please sign in to add a comment. Registration is free, and takes less than a minute. Read more

Click here to reset your password.
Sign in to get notified via email when new comments are made.