medically assisted dying

We must plan for our death

While our ultimate death is a certainty, when and how we will die is unknowable. And though death is inevitable, it remains a taboo subject for most. None of us knows what the future will bring. It is better to be prepared, so that if you become unable to make medical care decisions, your designated family members and healthcare providers, if you have talked to them, will have the knowledge and confidence to make those decisions for you.

As long as you are capable of understanding and communicating effectively with your doctor, nurse or other healthcare provider, you will be asked to make your own healthcare treatment decisions. But a serious accident or illness can result in you being incapable of making your own healthcare decisions at the time care is needed. This is why thinking about your preferences and talking to your future decision-makers now is so important. Making an advance care plan is a choice that will help alleviate some of the stress your family and friends could face if they are required to make important decisions for you, including who, exactly, you want your doctor to approach to learn about your wishes.

Advance care planning begins by thinking about your beliefs, values and wishes regarding future healthcare treatment and talking about them with selected family members or friends, as well as your doctor. When people you trust know what is important to you, it will be easier for them to make treatment decisions on your behalf.

Healthcare providers will always offer medically appropriate healthcare based on clinical assessment. They will want to ensure that any symptoms like pain, dizziness, nausea, bleeding or infection are understood and addressed. As long as you can understand and communicate, your healthcare provider will explain the medically appropriate care best for you, including any risks, benefits or alternatives. They will also ask if you have any questions and if you wish to accept or refuse the proposed healthcare treatment.

Some of the hardest decisions deal with the use of life support and life-prolonging medical interventions. These can include a ventilator to help with breathing, tube feeding, kidney dialysis, or CPR to restart the heart and lungs. If you were to have a life-threatening illness or injury, would you want to accept or refuse CPR? All, some, or no life support or life-prolonging medical interventions? A trial period of life support and life-prolonging medical interventions, allowing a natural death to occur if your condition is not improving?

Your advance care plan should at a minimum include these three things:

Having conversations with selected family members, friends, your family doctor and, if applicable, your spiritual leader, about your beliefs, your values and your wishes.
Writing down your beliefs, values and wishes for future healthcare treatment.
Writing down the contact information for the people who qualify to be on your temporary substitute decision-maker list (see below), or, if you prefer, the contact information for the representative you have chosen and named in an enhanced representation agreement, which is the one that allows you to name a person to make personal-care decisions and some healthcare decisions, including decisions to accept or refuse life support or life-prolonging medical interventions for you. (If you choose to have a representative agreement, I recommend you seek legal advice).

Bear in mind that your health and personal circumstances will change over time. As long as you are capable, you may change or cancel your advance care plan at any time and for any reason. Be sure to notify your doctor and your family members/friends of all changes you make.

Palliative care

When thinking about what to cover in your advance care plan, you might want to expressly include your wish to receive palliative care if you are suffering from a serious illness or condition. Palliative care is specialized medical care that focuses on providing patients with relief from the symptoms, pain and stress of a serious illness, whatever the diagnosis. The goal of palliative care is not to prolong life, nor to shorten it. The goal is to improve quality of life for both the patient and the family, and can be provided in a variety of locations, including the patient’s home, in a hospice, in a residential care facility or in a hospital.

Palliative care is provided by a team of doctors, nurses and other specialists who work with a patient’s other doctors to provide an extra layer of support. While often associated with end-of-life situations, palliative care is appropriate at any age and at any stage in a serious illness and can be provided alongside other appropriate treatments.

Many people choose to stay at home right to the end of their lives while receiving in-home palliative care from specialized healthcare providers. But if you are in the last few months of your life and feel that you are no longer able to manage at home, a hospice may be a good option for you. Hospices are meant to feel more like a home than a hospital. They are designed and furnished to provide a peaceful, homelike environment for you and your family while you receive end-of-life palliative care.

For more information on the delivery of palliative care in each of these settings, search the B.C. Health Ministry website or contact your local health authority.

Medical assistance in dying

Medical assistance in dying (MAiD) was made legal in Canada in 2016. It provides eligible patients who are experiencing intolerable suffering due to a grievous and incurable medical condition the option to end their life with the assistance of a doctor or nurse practitioner.

If your beliefs and values allow you to consider MAiD in the face of intolerable suffering, you should start by speaking with your doctor or your local health authority. For a variety of reasons, not all doctors will provide MAiD, and no one is required by law to do so. For some, MAiD may conflict with their personal beliefs or professional ethics. However, a patient can expect to be provided with information on how to access this service. Healthcare providers must not discriminate against patients with beliefs or values different from their own, and must provide an effective transfer of care to another healthcare professional who does offer MAiD.

To be eligible for MAiD, a patient must meet all of the following criteria:

be registered under B.C. Medical Services Plan
be at least 18 years old and capable of making healthcare decisions
have made a voluntary request for medical assistance in dying that was not made under any external pressure. This request must be in writing and signed and dated in front of two independent witnesses
have given informed consent after having been informed of the other means that are available to relieve their suffering, including palliative care, and
on assessment by two independent doctors or nurse practitioners, are determined to have a grievous and incurable medical condition, which means they have a serious and incurable illness, disease or disability; they are in an advanced state of decline that cannot be reversed; the illness, disease, disability or state of decline causes enduring physical or psychological suffering that is intolerable and cannot be relieved under conditions that the patient considers acceptable; their natural death becomes reasonably foreseeable. (On Feb. 24, 2020, the Liberal government of Canada introduced a bill to further amend the Criminal Code to, among other things related to MAiD, allow eligible persons to pursue a medically assisted death whether their natural death is reasonably foreseeable or not.)

A patient who has requested MAiD must be given the opportunity to withdraw their request throughout the process, including immediately before the medical assistance is administered, and this withdrawal need not be in writing or in any other particular form. Just an indication of a change of mind will do. And be aware that only patients who are themselves capable of giving consent can request MAiD. A request by a substitute decision-maker or by way of an advance directive is not valid.

Start the discussion

There is much more information available on end-of-life options than touched on in this article, and many matters not covered herein, but there is enough here to allow you to begin a conversation with those in your life who you want to make decisions for you when you cannot.

This is a lot to cover in one conversation. You can have as many conversations as you need – just get started before unwelcome circumstances make it too late. You will be doing yourself and your loved ones a big favour.

Tony DuMoulin is a founder of the law firm of DuMoulin Boskovich, where he practised commercial and real estate law for 40 years. He has a long history of involvement in Jewish organizations and municipal projects. DuMoulin is on the executive board of Jewish Seniors Alliance, in whose magazine, Senior Line, this article originally appeared in July 2020, Vol. 27(2).

Jewish take on health issues

Attendees engaged with panelists, left to right, Drs. Eric Cadesky, Brian Bressler and Jennifer Melamed at a Kollel event Jan. 29. (photo from Kollel)

A small but passionate group gathered at the Ohel Ya’akov Community Kollel Jan. 29 to engage with Drs. Brian Bressler, Eric Cadesky and Jennifer Melamed on the topic of Canadian Health Care Challenges Through the Jewish Lens, which focused on the legalization of marijuana, the treatment of addiction, the practice of harm reduction, the opioid crisis and medical assistance in dying (MAiD).

Cadesky, who chaired and moderated the event, is a family doctor in Vancouver and president-elect of Doctors of B.C.; until last summer, he was also medical coordinator at the Louis Brier Home and Hospital, a position he held for some eight years. Bressler is a gastroenterologist at St. Paul’s Hospital and a clinical assistant professor in the University of British Columbia’s department of medicine, while Melamed is co-owner of the Alliance Clinic, an addiction services facility in Surrey.

Bressler framed the conversation in terms of what he called the four principles of medical ethics for a healthcare provider: autonomy, respecting a patient’s choice and their right to understand and consent to treatment; beneficence, doing or recommending everything that could benefit a patient; nonmaleficence, taking into account all known risks to a patient and doing no harm, or the least amount possible, if harm is unavoiadable; and justice, making treatments available to all patients.

“I wouldn’t distinguish between those principles and Jewish ethical principles,” said Bressler. “I think they’re entirely consistent.”

Within this framework, the doctors’ dialogue with the audience took place.

One exchange was sparked by Melamed’s criticism of harm reduction clinics. “This is the dilemma we face,” she said, “is addiction insanity? Should we respect the patient’s autonomy even if the addiction has impaired that autonomy and they are not truly free to make decisions for themselves anymore because of the effects of the addiction?”

She said, “I refuse to accept harm reduction as the end result, as the highest result for my patients.”

Arguing that there “is really no such thing as a safe injection,” she said she believes such clinics are doing more harm than good.”

An audience member countered that recovery might be a realistic goal for working and middle-class patients, who have seemingly more to recover for; but, for addicts living in extreme poverty, who have a history of trauma and/or mental illness, they may not have a realistic chance of recovery. “With harm reduction, we keep them away from crime and treat them like human beings.”

The Kollel’s Rabbi Avraham Feigelstock said that, from a Jewish point of view, the community has a responsibility to do everything in its power to help a person recover. However, the question of how harm reduction clinics could go beyond their current purpose and move towards recovery was not pursued.

Discussing opioid use, Bressler expressed both a cautionary approach, based on his own practice (Crohn’s patients are at particular risk for addiction), and the opinion that it is important to focus on addressing the sources of pain, not just pain itself.

Both Bressler and Melamed were negative about the legalization of marijuana and its use in a medical setting. They said there was some evidence that marijuana was effective for a very limited number of conditions – neuropathic pain and nausea were mentioned – but that the risks of marijuana, such as cognitive impairment and a link to developing psychosis, were well-evidenced.

Melamed expressed concern about what she thinks will be the massive costs of policing marijuana intoxication, among drivers or industrial workers, for example.

When one person raised the potential of increased teen use of the drug, Melamed said teens were already using and she didn’t fear an increase, though she was concerned about the potential for increased use among adults.

Another audience member suggested the Jewish community should protest marijuana’s legalization.

The doctors took a less defined stance towards medical assistance in dying. Both Bressler and Melamed said they had personal and professional experience with it but did not take a stand in favour or against it, instead highlighting issues to consider. Bressler acknowledged the right of Canadians to MAiD but also pointed out that the practice conflicts with Jewish law.

Feigelstock said the general principle in Judaism is to prolong life but not necessarily to prevent death. “According to Jewish law, generally speaking, you may choose not to do things to prolong the life of someone who is dying,” he explained, “and you may give medicines to relieve suffering, which have the side effect of possibly shortening life, but you do not do something that will directly kill the patient. Every case must be dealt with separately, however, case by case; one cannot make general statements about what to do.”

Matthew Gindin is a freelance journalist, writer and lecturer. He writes regularly for the Forward and All That Is Interesting, and has been published in Religion Dispatches, Situate Magazine, Tikkun and elsewhere. He can be found on Medium and Twitter.

At controversy’s centre – Louis Brier

Louis Brier Home and Hospital has accused Dr. Ellen Wiebe, who specializes in medically assisted dying, of wrongdoing, for providing a medically assisted death to 83-year-old resident Barry Hyman, without the consent or knowledge of the care facility.

The home accused Wiebe of “borderline unethical” behaviour and has filed a complaint with the College of Physicians and Surgeons, but Wiebe is adamant that her actions were not unprofessional.

“By far the most important thing is the patient,” Wiebe told the CJN. “The second is the family. Mr. Hyman’s wish was to die in his home. People have all kinds of wishes and desires, but dying wishes are held to a higher standard than other wishes.”

Asked about the family’s agreement to abide by Louis Brier’s policies, and the dispensation given by the B.C. Ministry of Health for institutions to refuse the provision of services that go against their religious beliefs, Wiebe said, “I’m not part of those agreements. My agreement is purely with my patient, not the facility, and since I don’t have visiting privileges at Louis Brier like I do at Vancouver General Hospital, I am not required to abide by the agreement between Louis Brier and the ministry.”

Wiebe was invited into the facility by Hyman’s daughter, Lola Hyman, and his other immediate family members, who wanted to honour Barry Hyman’s long-held wish to die on his own terms. Disabled by a stroke and diagnosed with lung cancer, Hyman had asked to die at the care facility, which had become his primary residence. Lola Hyman had broached the topic with David Keselman, the chief executive officer of Louis Brier, who told her it was against their policy, which is formulated according to Orthodox Jewish law.

Lola Hyman told the Globe and Mail that she wanted to honour her father’s wishes in a place that was comfortable for him, not somewhere that would be unfamiliar to him.

On the night of his death, she said, “the room was very quiet. We just held his hand and stared at him. My sister was sobbing, just sobbing. I was a stone. A complete stone. My heart was racing that someone would open the door.”

The Supreme Court of Canada struck down the Criminal Code prohibition on physician-assisted dying in 2015 and the federal government passed legislation legalizing it in 2016. The court recognized that doctors should not be coerced into performing the procedure against their will, but did not specify whether health-care organizations could refuse to comply.

In British Columbia, the Ministry of Health made an agreement that allows members of the Denominational Health Association (DHA), which includes the Louis Brier, to refuse to provide services that are inconsistent with their religious values.

“Anyone who comes here knows what our policy is and, if they don’t like the policy, they should go somewhere else,” Mark Rozenberg, the chair of the ethics committee of Louis Brier’s board, told the Globe and Mail.

Keselman declined the CJN’s request for comment, saying that the board was in meetings to decide how to respond to the media exposure. The home’s rabbi, Hillel Brody, said he was not permitted to discuss Louis Brier’s policies with the press.

Shanaaz Gokool, chief executive officer of Dying With Dignity Canada, told the CJN that organizations like Louis Brier are not being asked to take part in medically assisted dying, but simply not to obstruct residents from a medical service to which they have a right.

“The doctors bring in their own equipment. The health-care facility has no involvement in the procedure. By not allowing this, they are undermining the rights of the residents of Louis Brier who call it their home,” Gokool said.

It is not clear if institutions that refuse to allow medically assisted deaths on their premises enjoy the same Charter-protected religious freedoms as individuals who refuse to provide the service, because the issue has not yet been tested in court.

A joint statement issued by Dying With Dignity Canada and the Canadian Association of MAID Assessors and Providers said, “We support health-care professionals who, as a matter of conscience and compassion, help their patients overcome unfair barriers to access.… And we will defend clinicians who are attacked or punished for their participation in the lawful provision of MAID (medical assistance in dying). These courageous individuals should be applauded, not penalized, for putting their patients first.”

Louis Brier is one of a number of faith-based organizations that are in a quandary: although the centre is run in accordance with Orthodox Jewish law, not all residents are religious Jews, and it also has non-Jewish residents.

A 2014 Ipsos-Reid poll conducted on behalf of Dying With Dignity Canada showed that 84% of Canadians were in favour of allowing physicians to help someone die, if that person is suffering and wishes to die.

There is also the issue of public funding, as “67% of the Louis Brier’s funding is public,” said Gokool. “They are funded by taxpayers and should abide by Canadian law.”

Lola Hyman told the Globe that she was left feeling distressed, both at the possibility of Wiebe suffering on account of helping her father, and at having upset the front-line staff at Louis Brier, who were shocked by Barry Hyman’s sudden death. She said that all of this could have been avoided if British Columbia went the way of Quebec and stopped allowing publicly funded organizations to obstruct the rights of their residents.

“Everyone is entitled to their religious beliefs and traditions and customs,” Hyman told the Globe. “But, when it comes to somebody who is very sick and dying, we need to have a different approach.”