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Preparing for assisted dying legislation

Shortly after the Supreme Court of Canada’s decision on assisted death was announced, I wrote a blog article on how we will need to address the upcoming changes to legislation within our faculty. Just two months later, this topic remains high in the public consciousness. As such, Post Media health reporter Sharon Kirkey contacted me recently to discuss how medical schools might begin to prepare for this change. I was pleased with the corresponding article that Ms. Kirkey produced, and felt that it accurately captured my views. The piece went on to be published in the National Post, Vancouver Sun, Montreal Gazette, and eight other established print editions across the country.

I would like to take the opportunity to share the article with you this week. Please feel free to share your comments on the article below, or better yet, drop by the Macklem house – my door is always open.

Richard

 

Canadian medical schools readying doctors to talk to patients about assisted suicide

By Sharon Kirkey

Canada’s medical schools are preparing for what was once unimaginable — teaching medical students and residents how to help patients take their own lives.

As the nation moves toward legalized physician-assisted death, Canada’s 17 faculties of medicine have begun to consider how they will introduce assisted dying into the curriculum for the next generations of doctors.

It is a profound change for medical educators, who have long taught future doctors that it is immoral to end a life intentionally.

“If legislation passes, and if it becomes a standard of practice in Canada for a small subset of patients who desire assisted death, and where all the conditions are met, would we want a cadre of doctors that are trained in the emotional, communicative and technical aspects of making those decisions, and assisting patients?” asked Dr. Richard Reznick, dean of the faculty of health sciences at Queen’s University in Kingston. “We would.”

In its landmark, unanimous ruling in February that swept away Criminal Code prohibitions against doctor-assisted death, the Supreme Court of Canada gave Parliament one year to craft a new law — should it choose to do so  — that recognizes the right of consenting adults with a “grievous and irremediable” medical condition to seek a doctor’s help to end their lives.

Medical schools have begun to consider how they will adapt to a change in law, once it comes into force. When should classes on assisted-suicide and voluntary euthanasia be introduced? Would there be sufficient numbers of faculty members willing to teach the next generation of their trainees in the art and science of assisted death? Would young doctors wishing to incorporate it into their practices for consenting patients first have to demonstrate they are appropriately skilled?

“There will be many complexities to this — it’s not going to be a simple process — and whatever we teach our medical students will have to be congruent with the legal parameters, the professional guidelines that are developed and the way that this may be carried out in the future,” Dr. Reznick said in an interview.

He stressed that it would be unacceptable to force any medical student or resident to participate in a medical procedure that is nevertheless legal. “We have to be respectful of the first principle here, that this is a choice,” Dr. Reznick said.

“There will be students who, for personal, religious or philosophical reasons, may not feel comfortable in ever thinking about themselves as perhaps participating in assisted death, as will be true of many physicians, perhaps the majority of physicians,” he said.

“It won’t be a mandatory core competency of any of our training programs.”

The issue has been brewing on medical school campuses since the Supreme Court denied Sue Rodriguez the right to a doctor-assisted death in 1993. Voluntary euthanasia (death by a lethal injection administered by a doctor) and assisted suicide (death by a lethal prescription the patient takes herself) are already discussed in medical ethics and health law courses, medical educators say, as are other difficult end-of-life issues, such as discussions around “do-not-resuscitate” orders.

“It’s not like we’re starting from ground zero on this,” Dr. Reznick said. Formal assisted-dying curriculum would likely be reserved for certain specialties in which future doctors are most likely to get such a request, say in family medicine and palliative care, although there is deep controversy among palliative-care doctors as to whether the role should fall to them.

Quebec’s “medical aid in dying” law, Bill 52, is expected to come into effect in December.

Until the law is implemented, said Maryse Grignon of McGill University’s office of undergraduate curriculum implementation, “it’s premature to incorporate [assisted dying] formally into the curriculum.”

However, once new federal or provincial laws and policies are in place, “this would need to be introduced definitely in the early stages of medical school,” said Dr. Genevieve Moineau, president and chief executive of the Association of Faculties of Medicine of Canada.

Together the schools graduate more than 2,300 doctors a year, have more than 10,000 undergraduate medical students in training and more than 12,000 postgraduate trainees.

The challenges facing medical schools echo abortion, “where there were changes in laws that required changes in how we approach a topic in our Canadian curriculum and our practice,” Dr. Moineau said.

Canada’s abortion law was struck down in 1988. No doctor is forced to perform abortions; however early termination of pregnancy is now a component of residency training in obstetrics and gynecology.

Dr. Jacques Bradwejn, dean of the University of Ottawa’s faculty of medicine, said simulation exercises could help students practice dealing with requests for assisted death, including how to evaluate the severity of a patient’s suffering, dealing with families and, ultimately, “whether this is the right thing, the ethical thing, to do.” “There would (also) be modules to teach how to use the various (life-ending) medications,” he said.

Dr. Reznick of Queen’s said that, despite “all our best efforts in palliative care,” many patients with incurable diseases face an “agonizing” death.

“My own personal view, as a citizen, as a doctor, is that I do believe that this will, for some patients, provide a comfort and a relief that’s necessary in certain illnesses,” he said.

Craig Goldie

Fri, 06/30/2017 - 10:05

Dr. Reznick,

I appreciate this article. It’s an issue all physicians and all medical schools will need to discuss and struggle with. Palliative physicians, as we are “at the coalface” so to speak, are discussing this at every level, nationally at the Canadian Society of Palliative Care Physicians (CSPCP), provincially and locally in Kingston as the palliative medicine group.

I do disagree with a few statements in this article. I don’t believe there is significant controversy within our specialty as to whether the euthanasia and physician-assisted suicide should fall within palliative care. There is relatively robust agreement that palliative care does not include euthanasia or physician-assisted suicide and therefore should those acts not be considered “palliative care”. That includes palliative care physicians both for and against the legality of the practice.

I would point you to the WHO definition of palliative care which includes the following:

Palliative care:

provides relief from pain and other distressing symptoms;
affirms life and regards dying as a normal process;
INTENDS NEITHER TO HASTEN OR POSTPONE DEATH;

[Capital emphasis mine]

Palliative care struggles already with a strong association with dying (and therefore medical failure) and this association likely leads to lower utilization and later referrals to our service, among many other misunderstandings of what we do by patients, families, allied health care and other physicians. Most palliative care physicians, including myself, do not think palliative care should “own” euthanasia or physician-assisted suicide.

We see ourselves as helping people live well with their illness. This of course includes dying well and honoring the person and their dignity, their goals of care, and wishes. In this new era, that will likely include honoring wishes for euthanasia and physician-assisted suicide. Our expectation is that this will include discussion of what palliative care can offer for that patient in the present and future, and if desired by the patient, a referral to a physician or service that can assess the appropriateness for physician-assisted suicide/euthanasia and provide it. That entire process is uncertain and hinges on how the government crafts the law in the next year. It seems very likely that it would require a team to assess the appropriateness of the requests. We also will have to struggle with patients who do not have necessarily the time or physical ability to attend or access these processes.

I also take issue with the belief that “many” patients face an “agonizing” death. Obviously I am biased in my work, but I am present at the end of life for a huge number of patients in my role, and I do not believe many face agonizing deaths. More often I believe it is those patients who have not accessed palliative care and those whose goals of care are not clear that face agonizing deaths with extreme interventions, procedures and aggressive treatment up to their very end of life. I believe the palliative care toolkit, including our excellent medications and such options as proportionate palliative sedation and interventional pain control (like intrathecal catheters) can achieve acceptable pain and other symptom control in the vast majority of patients.

We will certainly have a higher proportion and number of patients than most physicians who will want to know about physician-assisted suicide and euthanasia. We therefore have a significant role to play in how the conversation, law, and process for legal access to these interventions looks. I also think physicians with strong moral or religious objections will still need to be able to discuss this legal option and refer to another physician as appropriate, much like procurement of abortions.

Despite all I have mentioned above, my personal view is exactly the same as yours. I do believe access to these interventions may provide a comfort and relief for some patients with some illnesses. Palliative care cannot completely resolve all that patients lose from their advanced illness: as demonstrated in Oregon, most patients choose physician-assisted suicide due to losing autonomy, becoming less able to engage in activities that make life enjoyable, and loss of dignity. Fortunately it is rarely an issue of symptom burden and we try to emphasize dignity and whole person-hood in the care we provide, but I will be the first to agree it is never perfect.

I often tell patients I can remove the things that their illness is causing them: pain, nausea, dyspnea etc. but it is much harder to add back the things that illness has taken from them: cachexia, functional decline, fatigue and weakness. Much focus in palliative care is on improving those areas and there are exciting developments in understand cancer anorexia and cachexia that hopefully can lead to improved treatments in those areas.

I am unsure how much of a role I will personally play in euthanasia and physician-assisted suicide. I expect some of my patients will request it, and I will agree with many of them that it is appropriate for them. More importantly I will respect their autonomy to make their own decision, whatever my personal beliefs are. I may even play a role in providing it somehow, although how we organize the process and team around this critical area remains to be seen. I also do have significant existential concerns about balancing the relief of suffering in my patients with the personal weight and responsibility of ending a life earlier. Whatever patients and other physicians say, I have never intentionally shortened a patients life with my treatments, nor I am not aware of any palliative physicians who have.

However it looks, I will not be calling euthanasia and physician-assisted suicide palliative care and I will not present it as palliative care. It is not palliative care. It should live alongside it, and all patients should be able to receive excellent palliative care to the end of the life – whether naturally from their disease or from physician-assisted suicide or euthanasia.

Craig Goldie

Dear Craig,

Thank you for your thoughtful comments. I urge our readers to look at it in its entirety. You have articulated, certainly better than I could have, the intricate interplay between palliative care and assisted death. You also highlight the important separation that must be made between the two. I applaud your response and feel strongly that an experienced voice like yours needs to help guide the profession through our difficult future decisions.

Richard

reznickr

Dear Craig,

Thank you for your thoughtful comments. I urge our readers to look at it in its entirety. You have articulated, certainly better than I could have, the intricate interplay between palliative care and assisted death. You also highlight the important separation that must be made between the two. I applaud your response and feel strongly that an experienced voice like yours needs to help guide the profession through our difficult future decisions.

Richard

reznickr

Deb Dudgeon

Fri, 06/30/2017 - 10:07

In reply to by student

Dr Reznik,
I agree with much of what Craig says but not all. I think it is essential for euthanasia and physician assisted suicide to be seen as something completely outside the practice of Palliative Medicine. Many of us have stuggled for over 20 years to try to disengage the word “palliative” from terminal care and to assure patients that what we provide is not a shortened life. These beliefs of patients, families and other health professionals have led to late referrals and significant unnecessary suffering of patients and families. A recent survey of palliative care physicians showed that over 70% of respondents did not believe that euthanasia and physician assisted suicide should be provided by palliative care services. As it is going to be legalized and probably performed by physicians, I think there should be certification required of those physicians who are going to perform it. This would help to ensure that it is done competently, and I hope, that all other options have been exhausted and not out of ignorance as to what is possible. I also think making it obligatory for physicians to perform, or refer if requested, has the potential of decreasing access to palliative care as I know there are a number of palliative care
physicians, in addition to myself, who would need to leave the profession.

Deb Dudgeon

Deb Dudgeon

reznickr

Fri, 06/30/2017 - 10:08

In reply to by student

Dear Deb,

Thank you for your comments. Like Craig’s they are also thoughtful and bring an additional perspective to this discussion. It is clear, that regardless of what transpires with legislation, we would all do well to engage palliative care physicians in seeking their advice on the multitude of issues that will emanate from prospective legislation. Thanks again for your views.

Richard

reznickr

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