Providing medical assistance in dying: Practice perspectives

Jessica Shaw, Ellen Wiebe, Amelia Nuhn, Sheila Holmes, Michaela Kelly, Alanna Just

Canadian Family Physician

Abstract |Objective: To explore the experiences of the first cohort of physicians to offer medical assistance in dying (MAID) in British Columbia. DESIGN: Qualitative study using semistructured, one-on-one interviews.

Setting: British Columbia.

Participants: Eight physicians who offered MAID in British Columbia in 2016. METHODS: The physicians were interviewed by telephone or by e-mail between 4 and 6 months after MAID was made legal in Canada, with follow-up in January 2017. Interviews were audiorecorded, transcribed, and analyzed through qualitative thematic analysis.

Main Findings: Participants believed that MAID was rewarding and satisfying work. They explained that some of the structural and emotional challenges related to providing MAID included the following: the refusal of faith-based institutions to provide information about MAID to patients, as well as their refusal to allow assessments or deaths to occur on site; having to deny MAID to patients who did not qualify for it; disagreements with colleagues who did not support the provision of MAID; dealing with the grief of family and friends who were present at the death; and feeling like they were always on call. While a few participants thought that the legislative restrictions of Bill C-14 were appropriate in the beginning when MAID was first available in Canada, most would like to see changes to the legislation to make it more aligned with the intent of the Carter decision, including broadening the eligibility criteria to include mature minors and people with advanced psychiatric diagnoses, having the ability to honour advance directives, and removing the requirement of death being in the reasonably foreseeable future for patients with grievous and irremediable conditions.

Conclusion: Physicians in this study explained that providing MAID is rewarding work; however, there are many challenges that complicate their ability to offer MAID to patients. The current MAID legislation in Canada should be updated to better serve the needs of patients.


Shaw J, Wiebe E, Nuhn A, Holmes S, Kelly M, Just A. Providing medical assistance in dying: Practice perspectives. Can Fam Physician. 2018 Sep;64(9):e394-e399.

Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate

Daniel P. Sulmasy, Ilora Finlay, Faith Fitzgerald, Kathleen Foley, Richard Payne, Mark Siegler

Journal of General Internal Medicine

Abstract

It has been proposed that medical organizations adopt neutrality with respect to physician-assisted suicide (PAS), given that the practice is legal in some jurisdictions and that membership is divided. We review developments in end-of-life care and the role of medical organizations with respect to the legalization of PAS since the 1990s. We argue that moving from opposition to neutrality is not ethically neutral, but a substantive shift from prohibited to optional. We argue that medical organizations already oppose many practices that are legal in many jurisdictions, and that unanimity among membership has not been required for any other clinical or ethical policy positions. Moreover, on an issue so central to the meaning of medical professionalism, it seems important for organized medicine to take a stand. We subsequently review the arguments in favor of PAS (arguments from autonomy and mercy, and against the distinction between killing and allowing to die (K/ATD)) and the arguments against legalization (the limits of autonomy, effects on the patient-physician relationship, the meaning of healing, the validity of the K/ATD distinction, the social nature of suicide, the availability of alternatives, the propensity for incremental extension, and the meaning of control). We conclude that organized medicine should continue its opposition to PAS.


Sulmasy DP, Finlay I, Fitzgerald F, Foley K, Payne R, Siegler M. Physician-Assisted Suicide: Why Neutrality by Organized Medicine Is Neither Neutral Nor Appropriate. J Gen Intern Med. 2018 Aug;33(8):1394-1399. doi: 10.1007/s11606-018-4424-8. Epub 2018 May 2.

An effective referral is still a referral

Sanasi Jayawardena, Alexandra A Majerski

Canadian Medical Association Journal

We are writing to respond to Dr. Steven Bodley’s letter: “Just the Facts on Effective Referral.” . . . The College of Physicians and Surgeons of Ontario’s (CPSO’s) effective referral policy for MAiD does not go far enough in protecting the religious freedom of physicians. . . It is unfortunate that the CPSO does not acknowledge that the provision of an “indirect” referral still renders the referring physician complicit. . . . medical students training in Ontario must now seriously consider taking their skills and talents to another province or jurisdiction in which they can practice their vocation in a manner that upholds their integrity. . . [Full Text]


Jayawardena S, Majerski AA. An effective referral is still a referral. CMAJ [Internet]. 2018 Feb 28; 190(7).

Physicians are not solely responsible for ensuring access to medical assistance in dying

Diane Kelsall

Canadian Medical Association Journal

Patients’ rights to access to medical assistance in dying (MAiD) trumps the religious rights of physicians under the Canadian Charter of Rights and Freedoms  –  or so says the Ontario Superior Court of Justice. But ensuring equitable access to health care is a societal responsibility and does not rest solely on the individual physician. Surely there is a way forward that ensures access for patients requesting MAiD without trampling on physician rights enshrined in law.


Kelsall D.  Physicians are not solely responsible for ensuring access to medical assistance in dying. CMAJ February 20, 2018 190 (7) E181; DOI: https://doi.org/10.1503/cmaj.180153

Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

G. Bravo, C. Rodrigue, M. Arcand, J. Downie, M.-F. Dubois, S. Kaasalaine, C.M. Hertogh,S. Pautex, L. Van den Block

Geriatric Nursing

Abstract

We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.


Bravo G, Rodrigue C, Arcand M, Downie J, Dubois M-F, Kaasalaine S, Hertogh CM,  Pautex S, L. Van den Block L. Nurses’ perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada. Geriatr Nurs. 2018 Jan 3. pii: S0197-4572(17)30319-1. doi: 10.1016/j.gerinurse.2017.12.002.

Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: A population-based mortality follow-back study

Sigrid Dierickx, Luc Deliens, Joachim Cohen, Kenneth Chambaere

Palliative Medicine

Abstract

Background: In the international debate about assisted dying, it is commonly stated that euthanasia is incompatible with palliative care. In Belgium, where euthanasia was legalized in 2002, the Federation for Palliative Care Flanders has endorsed the viewpoint that euthanasia can be embedded in palliative care.

Aim: To examine the involvement of palliative care services in euthanasia practice in a context of legalized euthanasia.

Design: Population-based mortality follow-back survey.

Setting/participants: Physicians attending a random sample of 6871 deaths in Flanders, Belgium, in 2013.

Results: People requesting euthanasia were more likely to have received palliative care (70.9%) than other people dying non-suddenly (45.2%) (odds ratio = 2.1 (95% confidence interval, 1.5–2.9)). The most frequently indicated reasons for non-referral to a palliative care service in those requesting euthanasia were that existing care already sufficiently addressed the patient’s palliative and supportive care needs (56.5%) and that the patient did not want to be referred (26.1%). The likelihood of a request being granted did not differ between cases with or without palliative care involvement. Palliative care professionals were involved in the decision-making process and/or performance of euthanasia in 59.8% of all euthanasia deaths; this involvement was higher in hospitals (76.0%) than at home (47.0%) or in nursing homes (49.5%).

Conclusion: In Flanders, in a context of legalized euthanasia, euthanasia and palliative care do not seem to be contradictory practices. A substantial proportion of people who make a euthanasia request are seen by palliative care services, and for a majority of these, the request is granted.


Dierickx S, Deliens L, Cohen J, Chambaere K. Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: A population-based mortality follow-back study. Palliat Med. 2018 Jan;32(1):114-122. doi: 10.1177/0269216317727158. Epub 2017 Aug 29.

Community pharmacists’ attitudes on suicide: A preliminary analysis with implications for medical assistance in dying

Andrea L. Murphy, Claire O’Reilly, Ruth Martin-Misener, Randa Ataya, David Gardner

Canadian Pharmacists Journal

Conclusion

Pharmacists are likely underestimating their frequency of interactions with people with thoughts of dying or with intentions to die either by suicide or through medical assistance in dying procedures. Pharmacists report empathetic responses for those with severe and incurable diseases wishing to end their life, but most do not support death by suicide or through medical assistance. From the preliminary analysis, a personal connection to mental illness or suicide does not appear to influence the permissiveness of pharmacists’ attitudes towards suicide. Framing effects in survey research for pharmacists have not been adequately considered, and more work is needed to determine how this influences the responses of pharmacists.


Murphy AL, O’Reilly C, Martin-Misener R, Ataya R,Gardner D. Community pharmacists’ attitudes on suicide: A preliminary analysis with implications for medical assistance in dying. Can Pharm J (Ott). 2017 Dec 1;151(1):17-23. doi: 10.1177/1715163517744225.

Navigating the new era of assisted suicide and execution drugs

Sean Riley

Journal of Law and the Biosciences

I. Introduction

Lethal medication provisions are in a precarious state. Over the past decade, pharmaceutical companies have attempted to stamp out the use of their drugs in executions, creating several economic and regulatory hurdles for access to these medications. As a result, patients seeking physician-assisted suicide (PAS) as well as death penalty states aiming to execute their capital offenders have been forced to turn to unregulated and dangerous alternatives for these drugs. This note attempts to unpack the quality, safety, and access issues emerging from these recent changes and to explore the implications for the future of these practices.

In order to fully grasp the exact mechanisms at work, this note will first offer a brief pharmacological description of the lethal medications and detail many technical aspects of their use. The next section provides a historical account of the past decade, illustrating the emergent quality, safety, and access issues. This note then evaluates the competing notions of ‘botched’ executions and ‘complications’ in PAS while analysing the standards set forward to measure safety and efficacy for each. Finally, this note closes by exploring the future of each practice in light of our discussion.


Riley S. Navigating the new era of assisted suicide and execution drugs. Journal of Law and the Biosciences. Volume 4, Issue 2, 1 August 2017, Pages 424–434, https://doi.org/10.1093/jlb/lsx028

Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada

Madeline Li, Sarah Watt, Marnie Escaf, Michael Gardam, Ann Heesters, Gerald O’Leary, and Gary Rodin

NEJM

Abstract
After Canada legalized medical assistance in dying (MAiD), the University Health Network in Toronto implemented a hospital-based MAiD program. UHN offers a framework for assessing patients for and providing MAiD while respecting the rights of patients and staff.


Li M, Watt S, Escaf M, Gardam M, Heesters A, O’Leary G, M.B., Rodin G. Medical Assistance in Dying — Implementing a Hospital-Based Program in Canada. N Engl J Med 2017; 376:2082-2088 May 25, 2017 DOI: 10.1056/NEJMms1700606

Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception

Julian Savulescu, Udo Schuklenk

Bioethics

Abstract:  In an article in this journal, Christopher Cowley argues that we have ‘misunderstood the special nature of medicine, and have misunderstood the motivations of the conscientious objectors’. We have not. It is Cowley who has misunderstood the role of personal values in the profession of medicine. We argue that there should be better protections for patients from doctors’ personal values and there should be more severe restrictions on the right to conscientious objection, particularly in relation to assisted dying. We argue that eligible patients could be guaranteed access to medical services that are subject to conscientious objections by: (1) removing a right to conscientious objection; (2) selecting candidates into relevant medical specialities or general practice who do not have objections; (3) demonopolizing the provision of these services away from the medical profession.

Savulescu J, Schuklenk U.  (2016) Doctors Have no Right to Refuse Medical Assistance in Dying, Abortion or Contraception. Bioethics. doi:10.1111/bioe.12288