Assisted death no longer illegal_Feb 2016

Assisted death no longer illegal; 'It's a monumental change. It is a life-and death decision'
Published: February 10th, 2016

Byline: Paul Schliesmann

Canada’s doctors and healthcare professionals awoke last week to a new reality: That one of their patients might ask their assistance to die —and that person would have the legal right to petition the courts to do so.

“It’s a monumental change. It is a life-and-death decision,” said Dr. Cindy Forbes, president of the Canadian Medical Association. “This is not something physicians have been trained to do in medical schools. This is an ethical, moral, religious question. Physicians, like the general public, are equally affected by it. They share the same concerns.”

According to Forbes, a family physician in Nova Scotia, the immediate concerns for the OMA are to establish a “pan-Canadian approach” to help doctors navigate the new requirements for assisted death and to ensure that any one of the country’s 80,000 doctors is able to refuse that help as a conscientious objector.

“About 30 per cent of physicians said they would be willing to assist patients in dying. That was a year ago,” she said. “There would be a small group who feel it would be morally abhorrent to directly refer someone.”

Despite the preparations, Forbes said, “it won’t be clear what the system will be in the next four months. … There is some lack of clarity.”

Medical practitioners and professional groups have been scrambling to prepare for this day.

It was a year ago, on Feb. 6, 2015, that the Supreme Court of Canada struck down prohibitions against assisted dying in the landmark Carter case, clearing the way for competent adults suffering from a grievous illness, disease or disability to end their own lives with the help of a doctor.

Federal and provincial governments were given the intervening year to put in place guidelines for assisted death.

The federal government won a four-month extension, to June 6, but today assisted death is no longer illegal.

“It is vague and it’s changing daily,” is how Dr. Karen Smith, associate dean of education in health sciences at Queen’s University, describes the situation. “We’re in a time of interim guidelines.”

In her policy development role at Queen’s, Smith has been working with organizations such as the CMA to find out what training practising physicians will need to meet the guidelines that are being established.

Some doctors, Smith said, will need “basic level” training in order to respond to patients’ inquiries —and to know what their legal and professional obligations are, such as the requirement to refer a patient if they themselves don’t want to assist.

A more in-depth level of training will be needed for those who are willing to actively assist, either by administering a lethal drug, usually intravenously, or to supply someone with a pill can be self administered by the patient. “We’re not anticipating a huge number of physicians will need this [advanced] training,” Smith

said. She said that while assisted death is not part of medical school studies, medical students early on “come face to face with the realities of illness and disease.” “It isn’t a new topic,” Smith said. “We do a lot of teaching of ethics in our undergraduate curriculum.”

Last week, the Ontario College of Physicians and Surgeons released a set of interim guidelines to be used by doctors while governments take the next four months to put formal policies in place.

The temporary guidelines are clear on two important points: that in discussing the possibility of assisted death, doctors should present all treatment options to their patients, including palliative care, and that in “this time of regulatory uncertainty,” patients themselves must make the request and cannot rely on an advance directive or substitute decision-maker.

The CMA’s Forbes agrees: “We feel there really needs to be a full discussion about all the options. It’s part of obtaining full consent. Palliative care is a really important part of that discussion.”

The interim guidelines also make it possible for doctors and institutions to be conscientious objectors, however, they “must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.” The Registered Nurses’ Association of Ontario has also been carefully studying and debating the issue of assisted death on behalf of the province’s 108,000 registered nurses and 2,700 nurse practitioners.

CEO Doris Grinspun isn’t sure exactly how many of her members are supportive of the new legal requirement for assisted dying.

“I can only give you my hunch,” she said. “My answer is based on our annual general meeting debate and comments. I would say likely 65 per cent in favour of the court decision and 20 per cent opposed and the remaining don’t have a position.”

Grinspun doesn’t believe the new law will open a floodgate of demand for assisted deaths.

“Absolutely not. Look at Belgium. The numbers are minimal,” she said.

She cautions against getting caught up in a debate about right or wrong and, instead, believes Canadians should focus on upholding the rights of patients who may choose to die.

“It does not need to get resolved. We cannot expect the public or health professionals will be 100 per cent on anything so charged by personal beliefs, our religious choices,” she said. “This is about what the court has enabled us to do —uphold the choices of individuals. It’s not about resolving what health professionals think.”

She said that in order to provide assisted dying to people in remote and isolated areas of the country, governments will also have to consider designating nurses to step in for doctors.

“Certainly to include nurse practitioners. They are prescribers. In remote communities, RNs are all you have,” she said.

Grinspun also believes palliative care and assisted dying should be viewed as two choices on a continuum of patient care.

“For some persons, palliative care may be an alternative. For some it is point A —then, I don’t want it anymore,” Grinspun said. “The process is now much more difficult for health professionals. It has to do with this broader conversation about putting patients first. If a person makes that decision for themselves, it’s not necessarily because palliative care failed.”

Grinspun cared for both her mother and father at home, her mother dying of pancreatic cancer and her father of a lung condition.

During that difficult time, a social worker told Grinspun that her concern for her mother was unrealistic.

“You want to keep your mother with nothing hurting her. You can’t do that anymore,” the social worker told her.

Grinspun knows her mother would never have asked for death.

“My father would have chosen assisted dying,” she said. “I wish I had the choice. Every family has a story.”

Grinspun believes assisted dying challenges the core values of how nurses and doctors are taught about medical intervention.

“We take too much ownership of others’ lives at the end of life. It’s because we are trained to make it better,” she said. “If a patient brings [assisted death] up and you have had the dialogue and discussion about alternatives and they say ‘I have had enough,’ that’s their choice.”