Tag: assisted death

Medical help in dying

In June 2016, it became legal in Canada for a doctor or nurse practitioner to assist someone with their death, as long as they meet certain criteria under the law.

“We’ve been providing this service here ever since,” said Dr. Stefanie Green, who lives and practices in Victoria. “I am one of the medical-assistance-in-dying providers here in British Columbia. Before that, I was primarily a maternity doctor for 20 years, where I took care of babies and newborns.”

As it happened, the Jewish Independent caught up with Green at the end of a day she spent doing circumcisions. The doctor explained that she finds it uniquely interesting dealing with both the beginning and end of life. “There are a lot of similarities to me,” she said. “There’s a lot of overlap in terms of the emotion and skills involved.”

photo - Dr. Stefanie Green believes it “is a deep privilege to be involved in this care”
Dr. Stefanie Green believes it “is a deep privilege to be involved in this care.” (photo from Dr. Stefanie Green)

Growing up in Halifax and then doing her medical training in Montreal, Green made her way west almost 15 years ago.

Helping patients die on their own terms has been an increasing part of her practice, with about 70% of people choosing to end their lives at home, and the rest in a care home or hospital.

Medical assistance in dying is only available to people who meet specific criteria in Canada. These criteria include:

  1. The patient needs to be an adult, over the age of 18.
  2. The patient doesn’t have to be a Canadian citizen, but they must be eligible for Canadian health-care insurance.
  3. Patients need to be suffering from what is considered a grievous and irremediable condition; for example, a serious illness, disease or disability in an advanced state that is irreversible, causing unbearable suffering, and, ultimately, leading to the person’s natural death in the foreseeable future.
  4. The request needs to be made voluntarily; there can be no coercion by family, doctors or anyone else. It has to come directly from the patient and be made by the patient when she/he is capable mentally of doing so.

“If someone is interested, they have to make the request,” said Green. “There’s a specific form in every province that has to be filled out … that has to be witnessed as a legal document.

“Once the request is made legally, then someone like myself – a physician or nurse practitioner – would do an assessment with them, with the family, with the family doctor or specialist, with their records, and make sure they meet the criteria.”

If satisfied at this point, a second assessment is conducted by someone else. Only if both assessments find that the patient meets the criteria, can the patient then be considered eligible and have the power to give the go-ahead if they so choose.

The law stipulates a 10-day waiting period after the request is made before the procedure can happen, unless there are very specific circumstances that require it be otherwise. The procedure itself can be done in one of two ways.

The patients themselves can administer the medication by drinking a liquid the doctor or nurse practitioner provides. The mixture is made by a pharmacy, picked up by the doctor or nurse practitioner, and given to the patient. The nurse practitioner or doctor stands by to ensure all goes smoothly. “It’s not the tastiest of drinks and takes about an hour-and-a-half to be complete,” said Green.

The other option, which more people in Canada are currently choosing, is the physician-administered route. In this case, the doctor picks up the medicine from the pharmacy and brings it to the patient wherever they are. The physician administers it intravenously into an arm and the process takes about 15 minutes.

In the IV procedure, it is a mixture of medications. The first medication is an anti-anxiety medication to relax the patient. Due to its strength, it causes most patients to fall into a light sleep. The second medication is a local anesthetic used to numb the vein being used in order to avoid the chance that it could irritate the patient when the rest of the medication is administered. The third medication moves the patient from a light sleep into a deep sleep and then coma. Many people pass away during that sleep, but not always. The fourth medication paralyzes the body, so if anything is moving, like the respiratory muscles, it will be stopped. The heart will stop soon thereafter.

According to Green, there are a number of countries around the world that have some form of a medical-assistance-in-dying (MAID) team, but Canada is one of only four countries that allows both the patient-administered and physician-administered options.

“I think we allowed it and pushed forward on the law because Canadians feel very strongly that this is a very humane act,” said Green. “It’s something they want to have available.

“What our Supreme Court has decided is that this is actually a constitutional right of Canadians for this care. This is the ability of a physician or nurse practitioner to help someone who wants to end their life at the very end of their life, and who needs help to do so. That’s what this is – a very humane, peaceful and dignified act.

“I think the last poll I saw, 87% of the Canadian public supports this kind of care. I think that this is very respectful of the idea of patient autonomy. That’s what drives this.

“I think that, from an ethical point of view, as a physician, I have the duty to help heal people and to do the best I can to promote healthy life. At the same time, I’m also bound to reduce suffering. There’s a bit of a dichotomy there as a physician. In Canada, the law is reflective of the right of the patient; it’s not about the conflicted duty of the physician.”

From a Jewish perspective, Green does not anticipate any issue from the community. So far, she has done one case within the Jewish community (of a total of 31) and has not had any trouble.

At the time of her interview with the Independent, the MAID program had overseen two to three percent of all deaths on Vancouver Island over the previous six to eight months.

“People ask me a lot about how I feel about this work and what it’s like to do this work,” said Green. “I just want to stress that I do really believe this is a deep privilege to be involved in this care. I feel like I’m helping people. I find it very rewarding at the end.

“I don’t do it for the reward,” she said, “but have been absolutely overwhelmed by the gratitude expressed by the patients I work with and their families. It’s been surprising to me, the extent of that. I want people to know that the service is available and that it’s legal. There are people out there willing to provide this care, and I think it’s a great step forward in Canada. I’m very proud of the work I do.”

Rebeca Kuropatwa is a Winnipeg freelance writer.

Compassion in the face of death

Last week, the Supreme Court of Canada unanimously struck down the law that makes it illegal for doctors in Canada to provide medical assistance to severely ill patients who wish to die.

The court decision permits physicians to assist in the suicide of “a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition, including an illness, disease or disability, that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

The decision reflects a fundamental shift in societal opinions toward end-of-life issues. It is worth noting, at this point, that attitudes toward death, life and intervention have never been static. As medical technologies advanced in recent decades, some (primarily religious) voices argued that these technologies interfere with the will of God by “artificially” extending life. Now, the reverse is apparently true. It tends to be religious voices today arguing that, in some cases, the withdrawal of life-extending technologies and treatments is akin to exercising the prerogatives of the Divine in ending life.

Whatever moral concerns surround this serious issue, an understandable dissonance has affected Canadians’ attitudes: it has been noted that there are times when we force human beings to endure suffering at the end of life beyond what we would permit our pet animals to experience.

Many Canadians who have watched loved ones suffer excruciating and slow illness and deaths recognize that human suffering could be more compassionately ameliorated. Among the first steps should be the provision of the best palliative care available. When absolutely no better option exists, assisted death may be the best choice for some individuals. Most of us can see this. We may wish it weren’t so and, of course, we hope we and our loved ones are never faced with these decisions. The fact is, many of us will.

Yet, every instance in which an individual, their family and doctor make decisions about end-of-life preparations must be entirely individualized. There is absolutely no way that one can apply the same criteria to two cases. Circumstances are not transferable between diseases, patients, families or belief systems. Two people with identical conditions and prognoses may justifiably choose diametrical endings.

Indeed, we must ensure that assisted death does not become a go-to “solution” when alternatives exist, or that any patient feels the slightest pressure to choose it. There is a real danger that some people will weigh decisions not on what is best for themselves but what they perceive as best for others or based on what others in similar situations have done. Not wanting to be a “burden” should not be a legitimate justification for assisted death.

There is genuine and justifiable fear around the potential for a “slippery slope.” It is important to note that this Supreme Court decision deals

with the rights of an individual of sound mind to make a decision on their own in consultation with those they trust to end a life of suffering dominated by unbearable pain and the absence of hope for recovery.

Euthanasia is an entirely different matter. It does not involve an individual’s free and informed choice. The fear is that the acceptance of assisted death will make our society more amenable to – or at least less vigilant against – euthanasia. This is not a consideration to be dismissed. The sanctity of human life is too great to ignore the fact that human beings have the capability of justification for all sorts of things. So, as Canada engages in discussions about this ruling, we should also be vigilant in reasserting our fundamental beliefs that the value of life is not diminished by the legalization of assisted suicide, but rather our humanity and the right of all Canadians to a decent life and a respectful death is part of a worldview that is life-affirming.

Certainly there is nothing happy about this subject, but if this decision makes the end of life more bearable for some Canadians then it should be welcomed. Safeguards are absolutely crucial and, as a society, as families and as individuals, we must discuss and understand the limits and potential misuses of this new freedom.

It is so important that we as a society get this right. The federal government will address this issue in the coming months. The Supreme Court has spoken, as often happens in this country, leading legislators in social progress. It’s our turn now. Canadians should have a long, thoughtful and nuanced discussion on this topic.