Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical...

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Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec Université Laval, Québec City Family Medecine Forum, College of Family Physicians of Canada Palais des Congrès, Montréal (Québec) November 10, 2017

Transcript of Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical...

Page 1: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Story of Life, End-of-Life and Dignity

Medical Assistance in Dying (MAID)

Alain Naud MD CCFP(F)CHU de Québec – Université Laval, Québec City

Family Medecine Forum, College of Family Physicians of Canada

Palais des Congrès, Montréal (Québec)

November 10, 2017

Page 2: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Disclosure

Board member, Québec College of Physicians

Board member, CHU de Québec – Université Laval

No conflict of interest with the topic of this presentation

Page 3: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Plan

1) Québec Bill no 2, C-14, SCC

2) Preamble

3) Myths, falsities and misconceptions

4) Assessment and accompaniment

5) Procedure

6) Keynotes

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Québec Bill no 2

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Québec Bill no 2

Loi sur les soins de fin de vie

An Act respecting End-of-Life Care

http://www.assnat.qc.ca/en/travaux-parlementaires/projets-loi/projet-loi-52-41-1.html

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2009, Dec 4 Special parliamentary commission

« Mourir dans la dignité »

« Dying with dignity »

2014, June 10 Bill passed with 81 % of votes

No abstention

2015, Dec 10 Went into effect

Page 7: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Québec Bill no 2An Act respecting End-of-Life Care

June 10, 2014

Includes :

Palliative care

MAID

Palliative sedation

Advanced medical requests (excludes MAID)

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Main differences with C-14

Must be end-of-life condition

3 witnesses at signature

No 10 days mandatory waiting time

No assisted suicide

No nurse practitioners, only MD

Assessor must be provider

Mandatory declaration form, within 10 days

No coroner inquiry

All public health institutions MUST offer MAIDonly exception: semi private hospices (28 / 32)

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Canada Bill C-14 June 17, 2016

Natural death reasonably foreseeable, with no

prognosis necessary

10 days mandatory waiting time

Page 10: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Supreme Court of CanadaFeb 6, 2015

Grievous and irremediable condition

(illness, disease or disability)

that causes enduring suffering

that is intolerable to the individual

Page 11: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

The right to live

must not be transformed into

an obligation to live

Supreme Court of Canadaunanimous 9-0 judgementFeb 2015, Carter decision

Page 12: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Preamble

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MAID

is a

clinical, medical, moral, ethical

legitimate and completely legal

CARE

Page 14: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

MAID IS NOT a SHAMEFUL care

No patient has to hide from asking

No caregiver has to hide, justify or excuse frombeing involved

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MAID is

Everything BUT a simple lethal injection

It`s an end-of-life accompaniment of an incurable,

suffering and hopeless patient

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No opposition pall care - MAID

End-of-life options

- Denial of care

- Palliative care (PC)

- MAID

- Terminal sedation

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MAID is in no way against PC

With PC and others end-of-life options

MAID is FOR the patients

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MAID

is an

end-of-life accompaniment

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The only worthy DEATH WITH DIGNITY

is the one a

well informed and competent patient

will choose freely for himself, in accordance with

HIS OWN values, beliefs and convictions

Page 20: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

It’s easy to debate or philosophize

over the meaning of death and suffering

when others are facing it

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Concientous objection

Well protected by current laws + MD College guidelines

Comes along with obligations

- to withdraw from all the process surrounding MAID

- to transfer requests to a colleague

- to assume or ensure continuity of care

Gives you NO RIGHT to harm process or patient

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Page 23: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

5 hospitals

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• 1st in Québec

• 3rd in Canada

• 2 K population served

• 1 650 MD, Ph, Dt

• 1 700 beds

• 14 000 employees

Located in Québec City

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Le CHU de Québec-Université Laval

▪ 4 pall care units

▪ 5 800 cancer patients hospitalised / y

▪ 2 700 deaths / y all causes

▪ 1 700 deaths / y receiving pall care

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Raw datas with MAID at CHU de Québec

How many ?

Who ?

How ?

When ?

Page 27: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

MAID at CHU de Québec – U.L.

2016 58 patients 2,1 % of all deaths

Up to sept 2017 115 patients 2,1 % of all deaths

MAID in the Province of Québec

2016 461 patients 0,7 % of all deaths

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Raw datas with MAID at CHU de Québec

How many ?

Who ?

How ?

When ?

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Myths

Falsities

Misconceptions

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Physical suffering = only physical pain

Variant: Well controlled physical pain eliminates requestor eligibility of a patient for MAID

FALSE

Physical sufferingmay also be

Uncontrolled physical pain very uncommonly main issue

PSYCHIC suffering the most common, + physical sufferings

Cachexy Dyspnea Dysphagia

Paralysis Complete bed rest Wounds

Hemorrhage Bowel occlusion Exhaustion

Transfusions, punctures, repeated procedures

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Patient who receives good pall care never request MAID

Variant: requests for MAID are the sign of a defective access to good pall care

TOTALLY FALSE

Parallel with terminal sedation Experience at CHU de QuébecRejection of pall care by some patientsNumerous requests for MAID in hospices in the province

Good pall care are essentials, but can’t relieve everythingor are denied by some patients

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It’s forbidden to talk about MAID with a patient, unless he asks specifically for it

FALSE

Offense to deliberately hide a care that’s legitimate and legal

Obligation to bring up MAID into discussion, when appropriate - inform patient of available options- make sure of his understanding- with no judgement nor influence- respect the patient’s choice

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Obligation to set up a date at the assessment visit ?

NO

Assess eligibility

On follow-up visits, make sure that- patient is still able to consent- has not changed his mind

Page 34: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Patient must have tried everything before ?Must have received palliative care before ?

NO

Obligation to inform about alternatives and possibilities

Obligation to respect the patient and his choice

The patient is the only one who can bear witness of his own suffering We owe him total respect

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Mandatory 10 days waiting time ?

NO

No such waiting time in Québec Law

ALL end-of-life patients→ at risk of loosing ability to consent

It’s up to the assessor and second professional to decide

Page 36: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Agreement of families - relatives necessary ?

NO

Some family members - relatives are having a difficult time

Uncommon, but TRUE

Death will always be a difficult, unpleasant, even painful experiencePathologic mourning – dysfunctional individuals and families have always existed and will always exist. With or without MAID

MAID hasn’t been introduced to relieve families, friends and relatives

Obligation to protect the ill patient first. The patient is the boss

Page 37: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Assessment

and

accompaniment

Page 38: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Story of Life, End-of-Life and Dignity

Marie was her name…

Page 39: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Marie, 63 y

Married X 42 y, lives with husband

3 children, 4 grandchildren

Manager, financial institution

Practising Catholic

Former smoker, fit, living happy fulfilling life

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2015, Feb 14 Pulmonary adenocarcinoma stage IVNeoplastic pericarditis + tamponade3 lines of chemo, including experimental one

2015, Dec 15 Bowel occlusion NGTHospitalized in oncology

2015, Dec 23 Left pleural effusion pigtail tube

2015, Dec 24 She asked to stop chemo. Level of care IIConsultation with pall care team

2016, Jan 5 Level of care III (comfort care)Moved to pall care unit

Page 41: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Current status

• Bedridden• Unable to eat or drink• Weight loss +++ Emaciated +++ • Totally bald• NGT – urinary catheter – chest tube – IV line• Peritoneal carcinomatosis + occlusion• Ascites +++• Countless metastasis

Prognosis < 3 weeks

Page 42: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Medication

• Hydromorphone 0,6 mg s-c q 4 h • Dexamethasone 4 mg s-c qd• Quetiapine 50 mg by NGT qd• Dexlansoprazole 60 mg by NGT qd• Fluconazole 200 mg oral qd• Scopolamine patch q 72 h• Haloperidol 1 mg s-c BID PRN• Lorazepam 0,5 mg s-c QID PRN

Page 43: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

• Physical pain quite under control

• Physical suffering ++o Totally bedriddeno Extreme weakness and muscle waistingo Unable to eat or drinko Many uncomfortable tubes

• Psychological suffering +++o Loss of body imageo Loss of dignityo Completely dependent on otherso Remaining time meaningless and worthless

Page 44: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Thursday, Jan 7 Signed request form for MAID

Has already discussed it with▪ Family▪ Pall care MD▪ Hemato-oncologist▪ Social worker▪ Chaplain

Unconditional support from family

Page 45: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Thursday, Jan 7 Call for evaluation request

Friday, Jan 8 Encounter, private room2 h 50 to 5 h 30 PMInvolvement of care team

With ? Husband and childrenWhen ? Tonight !!!

Call MD for 2nd opinion + pharmacistMAID set for next day, Saturday, Jan 9, 11 h AM

Page 46: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Special requests

Empowerment powercontroldignity

Managing the family

Funeral home

Page 47: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Saturday, Jan 9

Daughter + husband overnight with her

10 h 00 AM Visit – confirmation of consentNGT removed – already central IV line

Champagne – coffee – toast + strawberry jamHospital pharmacy

10 h 55 AM Back at bedside11 family members + nurse

Page 48: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Saturday, Jan 9

11 h 00 AM Last farewells + hugs + kisses + whispered words

Totally serene and peaceful

Last confirmation of consent

“ Doctor, I’m ready. Let’s begin ! ”

Page 49: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Procedure

Page 50: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

➢ NaCl 0,9 % 10 ml

➢ 1- Midazolam 10 mg 10 ml 30 sec

➢ Xylocaïne 40 mg 2 ml 5 sec

➢ 2- Propofol 1000 mg 2 X 50 ml 5 min

➢ NaCl 0,9 % 10 ml

➢ 3- Cisatracurium 30 mg 15 ml 30 sec

➢ NaCl 0,9 % 10 ml

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Page 52: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Course of procedure

Attestation of death at 11 h 10 AM

Back in the room with family at 11 h 40 AM

Death certificate: cause of death is cancer, not MAID

Page 53: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

What does MAID bring up NEW or DIFFERENT

to patients?

to families and relatives ?

to caregivers ?

Page 54: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

1. « Insurance policy »

2. Relief – appeasement – pacifying

3. Empowerment

4. Always avoid terminal coma – agony stage

5. Allows planning – rituals of this moment with relatives

6. Family – relatives – friends at bedside

7. Communication capability preserved up to the end

8. Last words – farewells – hugs – kisses with family

9. Last words – farewells – hugs – kisses with caregivers

10. Less guilt for families (VS terminal sedation)

11. MD always at bedside with patient and relatives

12. Rapid, peaceful and painless death witnessed by relatives

Page 55: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Sept 22nd, 2016

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« If God cannot understand that,I don’t feel like

spending the eternity with him »Old dying and suffering lady,

devoted, practising catholic,

who asked for MAID

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« Who am I to judge ? »

Pope FrancisJune 26, 2016

Page 59: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

« When you don’t want to see,you don’t see »

Pope FrancisSeptember 11, 2017

Page 60: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

6 keynotes

Page 61: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

1

MAID is a

medical, clinical, moral, ethical

legitimate and completely legal

CARE

Page 62: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

2

MAID IS NOT a SHAMEFUL CARE

which one must hide, justify or excuse from

Page 63: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

3

MAID is everything BUT

a simple lethal injection

It’s an end-of-life accompaniment

of a suffering and hopeless patient

Page 64: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

4

It’s easy to debate and philosophize

over the meaning of death and suffering

when others are facing it

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5

No patient should ever have to pay

with his own suffering

the price of religious, ideological or personal

values, beliefs and convictions of some caregivers

Page 66: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

6

There is no opposition between

palliative care, terminal sedation, denial of care and MAID.

They’re all legitimate and legal end-of-care options,

which the free choice belongs exclusively

to the competent and well-informed patient,

in accordance with his OWN values, beliefs and convictions

Page 67: Medical Assistance in Dying (MAID) Alain Naud · Story of Life, End-of-Life and Dignity Medical Assistance in Dying (MAID) Alain Naud MD CCFP(F) CHU de Québec –Université Laval,

Thank you