Thoughts on Physician Assisted Dying

It has been an incredible month. We attended conferences in Texas, Ontario and California. We are home now, absorbing the learning, and trying to integrate what we learned into our beings. Most profound for me was the opportunity to attend sessions addressing Physician Assisted Dying.

The debate is over. Physician Assisted Dying has been legalized in Canada. Health care professionals and administrators in hospices and palliative care (HPC) now need to develop policies outlining what services their HPC program will and will not provide. Physicians need to decide how to respond to requests, whether or not they are willing to provide a “hastened death” and if not, then decide who to refer people to. Nurses need to decide how they will respond, both within their formal work setting, but also, how they will respond as a family member or friend when the questions about hastening death are raised.

The entire health care team will need to reflect on how to respond when someone chooses a hastened death over the services of hospice and palliative care. Will we feel like we have failed? And if we feel that we have failed, how will we sit with that in the coming days, or more particularly, in the nights ahead?

As a nurse, if I choose to attend a death that has been hastened, how will that be for me and for the others who attend? Rather than witnessing the physical changes that often occur over a matter of days and hours, how will it feel to watch a person go from alive and cognitively intact, to waxen, cold, and dead,…. in just moments?

A few people have asked me what I think and feel about Physician Assisted Dying. I have avoided sharing my thoughts over the past years… but am willing to share my thoughts and the process I am going through today. Please read my thoughts knowing that like many of you, I am trying to make find my way in this new territory. These are my thoughts of the moment.

For much of my life I have been involved with caring for people and creatures who were dying. I cared for family, friends, community members and patients. For decades I sought meaning in caregiving and in dying. I found meaning and value in the last weeks, days and hours at the bedside. I searched for the benefits of family sitting vigil. I tried to find the good in the challenges that occurred. I came to believe that there was growth at the end of life, growth in the dying days, and sacredness in the act of caring for and being with.

Not only did I find value in the process of dying, I also sensed that on occasion the dying person was able to choose when they wanted to die naturally. Over the years I have been asked by friends to be with them when they were dying. Interesting to me, is the number of times when despite my limits and inability to be with someone constantly, I was there when they died.

For example: many years ago, when we were both young moms, my friend was diagnosed with breast cancer. I went to Vancouver to bring her home to the island. As I left her side at the hospital that night, I told her that I would not be able to return for ten days. I felt awful that I could not be there until then. I kept in touch by phone, and sent messages along. Ten days later I drove the island highway and made my way to her hospital room. Alongside her husband and her sisters, we companioned her. We waited with her and she died.

A similar story has played out many times since. Someone asking, “Kath, can you be with me when I die? Can you be with my family?” Try as I might to be there, I was often not able to attend 24/7 because of family and work commitments. Yet, often, death and I, were there at the same time. Natural death seemed to have a plan of its own.

With the legalization of assisted death, I look ahead and consider a new request. I can imagine that if I was in the Washington or Oregon, the request might be, “Kath, can you come and be with me when I take my medications?” or if in Canada, the request might be, “Kath, can you be here when I receive the injection from the doctor? Can you be here with my family?”

I wonder. How will I respond? In both cases, I do not have to be the one to give the medication. All that I am asked is to be present.

The request is simple enough. But then the planning. The planning seems surreal.

In Oregon and Washington states, once the person has met all the criteria, the person can set their own time and take the medications in the privacy of their own home.

In Canada, the dying person will need to arrange with a physician to inject the medication into their blood stream. What happens if the person decides they would like to live for another day, another hour? Would the person feel they need to go ahead with the plan because the doctor had arrived?

And as I think of the injections, I am reminded of the presentation at the Canadian Hospice Palliative Care Association conference by Dr David Wright, a nurse at the University of Ottawa, who is exploring the nursing perspective on this issue. David asked excellent questions: What does the nurse experience if the dying person chooses a hastened death over hospice palliative care? ….. He then asked… or was it someone else who asked, “Even though the physicians inject the medication, how many physicians do you know who can start an IV without the help of a nurse?” Nurses are a part of this process.

At the California Hospice and Palliative Care Association Conference, Anne Koepsell put forward four categories for how hospices respond to the requests for Physician Assisted Dying:
Embrace: hospice designates a social worker to respond to the requests, physician provides the prescription, staff are permitted to be present at time of death, and the hospice coordinates with Compassionate Choices.
Educate and support: hospice staff provide referrals to someone who is willing to discuss and assist with hastening death, the staff may or may not be present when death occurs.
Distance: hospice staff refer to a resource who will address the request.
Denial: hospice refuses to allow staff to discuss the request, and does not make referral.

At this moment in time, these are the three things that I know for sure:

1. I do not like the term “Physician Assisted Dying”. It is my opinion and my hope that physicians should assist every person in dying. Hospice physicians assist the dying person. They do not hasten it. So, I prefer instead to use the term, “Physician Hastened Death”, or “Hastened Death”.

2. I would like to see a world where everyone does have a CHOICE, a real choice, and I would like to see that Hospice and Palliative Care are one option. At this time, less than 30% of dying people receive services from a specialty Hospice Palliative Care team. When a person lives in remote and rural areas, when a person is not from a middle class Caucasian family, the person is much less likely to access HPC!

3. Finally, all HPC professionals need to be comfortable with talking with dying persons about the option to have a hastened death. They need to be able to hear the concerns and questions, to share the resources for hastened death, and to share what hospice and palliative care have to offer.

We, hospice palliative care professionals are at the bedside of people when they ask these questions. We, know how to talk about difficult things, how to talk about goals of care. We know the resources, we know the options, we can advocate. We are with friends and family when they ask questions about hastening death. No matter what people decide, we need to be comfortable with the conversation.

What are your thoughts on “Physician Assistant Dying”? Please leave your thoughts below, or chime in on our Facebook page.

Medically assisted dying? First ensure universal access to Hospice Palliative Care

Last June the B.C. Supreme Court struck down Canada’s ban on assisted suicide. The federal government launched an appeal. Yesterday Bill 52 was tabled in the Quebec National Assembly to legalize medically assisted dying.

This bill would allow a physician who receive the repeated consent of a patient to administer medication with the specific purpose of causing death. This is different than the laws in four US states where the physician writes an order the the patient fills the prescription and takes the medication themselves.

I support the Canadian Hospice Palliative Care Association and the Canadian Society of Palliative Care Physicians (CSPCP) as they stress “the need to  ensure that all Canadians have access to Hospice and Palliative Care before legalizing assisted dying.

This is the most important message to share with neighbours, friends, politicians, health care team members. For more information, clarification, definitions, go to “Let’s Talk About Hospice Palliative Care First” campaign at: www.chpca.net/hpcfirst

Those who companion "Assisted Dying" require education and support!

In the article by Robert Cribb about Assisted Dying, he quotes criminologist Ogden who suggests that those who companion those who die by suicide or planned death, do not need to be trained professionals and that they do not need training.

Ogden states, “We don’t see a need for training because the person doesn’t need to know how life is ended because they aren’t going to be involved. The core requirement is to sit on your hands. It would be a violation of the law to intervene. If someone is struggling to end their life and you step in and finish the job, that’s murder.”

I disagree!  Even IF the person is ONLY to be a COMPANION or a WITNESS to the planned death, they deserve to be prepared for this experience with education. Just as hospice organizations prepare volunteers to sit with the dying, organizations supporting planned deaths should prepare their volunteers and staff with adequate education and support.

If the core requirement is simply to sit on your hands, as Ogden suggests, then why be there at all? The role of companion is to “be with”.  “Being with” usually requires more education and skill than “doing for”.

And if, the dying person does not complete suicide, either because the tools chosen were not effective, or because s/he changes their mind or because s/he struggles in the experience of dying…. all the more important to prepare the companion to respond in the moment as well as to address their own feelings in the days and years to come.

If/when Assisted Dying is legalized, new careers will emerge. It will be important that education is developed that ensures best care for the dying as well as supports health and healing for those who assist in the process.

Before we talk of Assisted Dying, let's ensure that all dying Canadians can access Hospice Palliative Care!

Robert Cribb’s article in The Star addresses Assisted Dying in a five part series addressing how Canadians are dying. It seems unlikely that the Boomers who fought for “Reproductive Rights” will not succeed at legalizing “Death Rights” including the right to chose “Assisted Dying”.

As Canadians participate in this discussion and laws change my greatest concern is that we CONTINUE to ADVOCATE or START to ADVOCATE to ensure:

  • hospice palliative care is accessible to all Canadians,
  • earlier in the disease process,
  • for people with any life limiting illnesses,
  • across all settings.

Currently less than 30% of dying Canadians receive the services of a specialty care hospice palliative care consult service.  Many only receive the service in the last days and weeks of life.

As I have shared in other blogs, Palliative Care Australia suggests that 65% of the dying can be well cared for by their primary health care team,  given that the primary care providers have basic education in a palliative approach.

A palliative approach, the integration of palliative principles and philosophy can be integrated in any setting, for people with any life limiting illness, earlier in the disease process.

In Canada two exiting research projects are exploring the integration of a palliative approach.

iPANEL  and Quality Palliative Care in Long Term Care are doing wonderful work as they explore ways to best integrate a palliative approach in “other settings”.