Physician Assisted Dying: Issues

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Physician Assisted Dying Issues Challenges
for Hospice Palliative Care.

• Larry Librach MD,CCFP,FCFP
• Head Division of Palliative Care, Dept of Family
  Community Medicine,
• W Gifford-Jones Professor of Pain Control
  Palliative Care, University of Toronto
• Director, Temmy Latner Centre for Palliative
  Care, Mount Sinai Hospital

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• I am neither a proponent for
• or
• an opponent of PAD
• I am advocating for us to be involved in and open
  to discussion

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A personal journey

• 30 years of palliative care
• Observing the changes in HPC
• Observing the magnitude of suffering
• Listening to patients families
• Cases

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What is palliative care about?

• Palliative care was developed to provide better
  care to the dying
• Relieve unnecessary suffering
• Comprehensive, holistic patient family centred
  care
• Respecting addressing the needs of patients
  families
• Dealing with a variety of choices

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What is palliative care about?

• Palliative care concerns itself with the quality
  of dying
• Just because we want to have a longer time with
  patients families we should not forget that we
  are about the good death
• Promoting hope may be nasty

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What is palliative care about?

• Palliative care is NOT an alternative to PAD
• It is a philosophy of caring for the dying
• PAD is an action to end a life because of
  intractable suffering
• So if we are about dying, we must confront the
  issues in PAD

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Case
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Hamilton

• 55 yr old man
• Presented 4 weeks ago with an acute bowel
  obstruction
• Before this felt unwell tired for 2 mo. but
  continued activities
• Large pancreatic mass, liver mets,
  intra-abdominal mets

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...Hamilton

• Married-wife Gayle a social worker-two daughters
  living in USA (Chicago Miami)
• Successful businessman philanthropist

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...Hamilton

• Gemcitabine chemo but recurrent bowel
  obstructions
• Sent home
• Symptoms
• Anorexia, abdominal pain mild, intermittent
  nausea, weakness
• Octreotide daily

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...Hamilton

• Wants to stay home to die
• Does all the things we would like to see patients
  do
• Pain controlled
• Complete bowel obstruction controlled by
  octreotide
• Not depressed
• Asks every visit ? can you help me die

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• What are the issues?
• For him, for you, for his family
• How would you approach his request for assisted
  dying?

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...Hamilton

• Dies with bowel perforation, severe pain
• Family traumatized
• why couldnt you help him?

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• However, despite access to high quality
  end-of-life care, a small number of Canadians may
  still choose to have control over their own
  death. As hospice palliative care practitioners,
  we will respect their right to choose will not
  abandon them. We will continue to provide the
  same compassionate care to these individuals
  their families, but we also have a choice not to
  participate or to be expected to assist in any
  efforts that intentionally hasten death.
• CHPCA Draft Statement

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• Death is not fair it is often cruel. ...Some
  die quickly, others quite slowly but peacefully.
  Some find personal or religious meaning in the
  process as well as an opportunity for final
  reconciliation with loved ones. Others,
  especially those with cancer, AIDS or progressive
  neurological disorders, die by inches in great
  anguish. Good palliative care can help in these
  cases, but not always and often, not enough.
  Marcia Angell

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A question of mercy?

• In the face of unbearable suffering, what do we
  do?
• Do we as a specialized discipline have developed
  professional pride that borders on hubris
  rigidity (Angell) not say that PAD is an
  option?
• Perils of dogmatism may exclude people or cause
  us to abandon people (Roy)
• Paternalism?You must continue to suffer because
  it is good for you

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A question of mercy?

• Whose life is it anyway?
• How do we respond to people to whom independence
  control are of prime importance?
• People die very much as they lived (Mount)
• Is PAD amoral?

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Suffering

• One of our competencies is to deal with suffering
• Suggesting that because unrelievable pain or
  intractable suffering rarely occurs it should be
  ignored follows a logic that has never motivated
  the practice of medicine that because a source
  of suffering is uncommon, it should not be
  attended to. (Cassell)

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Suffering

• If we are attuned to relieving as much suffering
  as possible, why cant we consider at times the
  option of PAD for those who make a valid
  reasoned request to end what is for them
  intolerable suffering
• We need to see the world as it occurs for them
  not impose our views on them
• Whose life is it anyway?

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AAHPM Statement 2007

• Despite all potential alternatives, some
  patients may persist in their request
  specifically for PAD. The AAHPM recognizes that
  deep disagreement persists regarding the morality
  of PAD. Sincere, compassionate, morally
  conscientious individuals stand on either side of
  this debate..

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.AAHPM Statement 2007

• AAHPM takes a position of "studied neutrality" on
  the subject of whether PAD should be legally
  regulated or prohibited, believing its members
  should instead continue to strive to find the
  proper response to those patients whose suffering
  becomes intolerable despite the best possible
  palliative care. Whether or not legalization
  occurs, AAHPM supports intense efforts to
  alleviate suffering and to reduce any perceived
  need for PAD.

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AAHPM Statement

• The most essential response to the request for
  PAD in the practice of palliative care is to
  attempt to clearly understand the request, to
  intensify palliative care treatments with the
  intent to relieve suffering, and to search with
  the patient for mutually acceptable approaches
  without violating any party's fundamental values.

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Legalizing PAD

• Should it be legalized?
• Will any one law ever cover the complexities
  diversities of human beings/nature? (Roy)
• Giving power of PAD to MDs who cannot communicate
  (Roy)
• What are they to listen to?
• Do they know what to say?

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Legalizing PAD

• Can we trust legislators with this difficult
  task?
• Euthanasia offices? Licenses?
• Will a public referendum be worthwhile?
• The issues are complex

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The slippery slope argument

• Posits a very negative impression of humanity?
  lawless, unjust, inhumane
• Based often on the eugenics genocide of the
  Nazi regime to frighten us
• Do we really believe that our society is that
  vulnerable?
• Is PAD a matter of descending into an abyss of
  evil?

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Other issues

• Do we have a right to impose religious morality
  on others since the majority of Canadians see
  themselves as secular?
• The best of palliative care may not avert
  requests we should not think we are failures
  because patients seek PAD

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Can HPC PAD co-exist?

• Oregon experience has shown that PC PAD can
  co-exist
• In that jurisdiction has focused attention more
  on PC
• Netherlands was an anomaly initially but now
  there is a legal framework palliative care
• Belgium Switzerland

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Can HPC PAD co-exist?Bernheim JL, Distelmans
W, Mullie A, Bilsen J, Deliens L. Development of
palliative care legalisation of euthanasia
antagonism or synergy? BMJ 2008

• Within Belgium we found few professional stances
  contending that palliative care legalisation of
  euthanasia are antagonistic, no slippery slope
  effects, no evidence for the concern of the
  European Association for Palliative Care that the
  drive to legalise euthanasia would interfere with
  the development of palliative care. Rather,
  there were many indications of reciprocity
  synergistic evolution.

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Can HPC PAD co-exist?Bernheim JL, Distelmans
W, Mullie A, Bilsen J, Deliens L. Development of
palliative care legalisation of euthanasia
antagonism or synergy? BMJ 2008

• Regulatory professional organisations
  implicitly or explicitly endorsed or accepted the
  concept of integral palliative care, which
  recognises the right of patients to decide that
  further conventional palliative care is futile
  to request obtain physician assisted death.

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Can HPC PAD co-exist?Bernheim JL, Distelmans
W, Mullie A, Bilsen J, Deliens L. Development of
palliative care legalisation of euthanasia
antagonism or synergy? BMJ 2008

• Beyond that, the societal debates made clear
  that most values of palliative care workers
  advocates of euthanasia are shared. If Belgiums
  experience applies elsewhere, advocates of the
  legalisation of euthanasia have every reason to
  promote palliative care, activists for
  palliative care need not oppose the legalisation
  of euthanasia.

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Summary

• I believe that palliative care must get involved
  in the discussions of PAD
• Taking a rigid approach will not allow us to
  explore issues with politicians and Canadian
  citizens