Physician Assisted Death: Challenges for Hospice and Palliative CareNuala Kenny, OC, MD, FRCP(C)

Professor Emeritus

Department of Bioethics

Dalhousie UniversityEthics & Health Policy Advisor

Catholic Health Alliance of Canada

Historical Perspectives on Physician Assisted Death (PAD) Longstanding prohibition Origins of ‘the right to die’-Quinlan case

Refusal of treatment Now-patients’ rights and autonomy issue

“The right to die as the triumph of autonomy”

Beauchamp, 2006 JMed & Philosophy

Today, claims to the ‘right’ to control the circumstances of one’s death AND to

Oblige another (physician) to assist

Some International Experience Oregon & Washington State

PAS Netherlands & Luxembourg

Euthanasia and PAS Switzerland-2002 Penal Code

AS UK actively debating the issue

Current State of End of Life Care-Canada

Refusal of Rx by competent patients allowed Withdrawal/withholding of non-beneficial Rx Drugs for pain control (Rodriguez Case) PAS illegal (Sec 241b of Criminal Code) Euthanasia illegal (Sec.229 of Criminal Code) Bill C-384 introduced to Parliament -3rd time

Bill C-384

Allows a person to legally request assisted suicide “free & informed consent”; appears to be lucid;

18>;written request x2; alternatives presented Any person in “severe physical or mental

pain without any prospect of relief” or “suffering from a terminal illness”

Respect for patient autonomy

Equality- Charter of Rights and Freedoms

Rejection of relevant ethical distinctions

Duty to relieve pain and suffering-non abandonment

PAD is occurring; better to regulate

Some Arguments For Physician Assisted Suicide

Some Arguments Against Physician Assisted Death

Respect for autonomy does not ‘trump’ all There are clear moral/ethical distinctions PAD is incompatible with physicians’ duties

Killing is not an act of medicine PAD is not necessary for good EOL care

Effective palliative care for pain and symptoms Slippery slopes are real

Assisted Death: Special Challenges for Hospice and Palliative Care

Hospice & Palliative Care (H&PC):Implications Of the Legalization of PAD Many of the requests will come in/to H&PC

50% of hospice nurses have had a request Ganzini et al 2008 Palliative Medicine; 22:659-667

Hospice and palliative care staff and supporters need to have an accurate and sophisticated understanding of the arguments

The special implications for hospice and palliative care need careful scrutiny

Is Assisted Suicide a Component of Palliative Care? Swiss Palliative Care Society-18% yes German “ “ “ -25% yes UK Association for Palliative Medicine-8% North America debate

For Quill, Battin Against Foley, Hendin

Hospice and Palliative Care: Philosophy of

Care

Hospice & Palliative Care WHO & European Union Palliative Care

Association definitions -hospice/palliative care “neither hastens death nor

prolongs dying” Share a concern for returning dying to the natural Affirm the goals of medicine in end of life care

Pain & symptom control AND the “last things” Recognizes the distinction between pain & suffering

Crucial Issues for Palliative Care Many already confuse palliative care with

euthanasia “Assistance in dying”- IS palliative care; PAD

is assistance in death “Death with dignity”-the importance of dignity

in palliative care (e.g.Chochinov et al) Polls showing public support for PAD but

very confused answers

Clarifying Terminology

Withdrawing/Withholding Non-beneficial/futile Rx (not care!) Not ‘passive euthanasia

Physician-Assisted Death Assisted suicide – intentionally killing oneself with

the assistance (i.e., the provision of knowledge and/or means) of a physician

Euthanasia – an act undertaken by a physician with the intention of ending the life of another person to relieve that person’s suffering Voluntary and involuntary

The Importance of Distinctions Killing vs “letting die”

Culpability-motive, intention & nature of the act Unrealistic notions of the power of medicine

Withdrawing/withholding Beneficial vs non-beneficial and harmful

interventions Pain control and “double effect”

Empirical evidence regarding pain control-effectiveness and NOT death-hastening

Terminal sedation

Good EOL Care & PAD:Reasons for Request (Oregon) Less common concerns

of those who elected to die Burden on family/

friends/caregivers (37%) Inadequate pain control

or concern about pain (22%)

Financial implications of treatment (3%)

Most common concerns of those who elected to die Losing autonomy (86%) Less able to engage in

activities that make life enjoyable (85%)

Losing dignity (83%) Losing control of bodily

functions (57%)

Requests for AD-A Systematic Review

Hudson et al Palliative Medicine 2006; 20: 693-701.

Requests common in those with advanced illness Will to live correlated more with anxiety and

depression than physical symptoms Multiple issues cause patient’s suffering.

Suffering takes time to understand Depression is more common in those who

request AD

Profiles of Persons Requesting AD Requests based on fear of the future Exhaustion/burnout from the illness Desire to control an out of control process Patients with significant depression Patients with a firm belief that it is their right

to choose the manner and time of their death. Zylicz 2002 in Foley & Hendin The Case Against

Assisted Suicide: For The Right to End of Life Care.

Slippery Slopes

Some believe careful legislation can guard against “slippery slopes” Empirical data on AD from Oregon (0.09% of deaths),

Switzerland (0.45%) the Netherlands (0.3% AS; 1-8% all AD) does not support some of the dramatic claims

However, slippery slopes are real Even if legalized for competent persons on the basis of

autonomy, there will be substantial shifts in thinking regarding all aspects of EOL care for all persons

Slippery Slopes

Starts with competent patient autonomy Alters profoundly relationship between physician

duty & patient autonomy Cannot be logically confined to terminal illness or

EOL care Examples of empirical slippery slopes

The “duty to die” AD for “life fatigue” The Dutch dementia debate The Groningen protocol-euthanzising handicapped

newborns

Dilemmas Experienced by H&PC Staff Regarding a Request for AD Responsibility for pain & symptom control Patient autonomy questioned AD contradictory to philosophy of H&PC Missed opportunity for spiritual transformation Concerns re interfering with autonomy when

trying to help redefine quality & dignity Conflicts over advocacy when patient &

family disagree on AD Harvath et al J Hosp Pall Nursing 2006; 8:200-09

Conclusions From The Swiss Experience-Pereira et al. AD is contrary to the philosophy of H&PC Allowing AD further confuses the public re

H&PC AD distresses many patients and families AD presents distress to many practitioners PC becomes a gatekeeper & perhaps

“dumping ground” for AD The dynamics of care change with AD

Some BIG Challenges for H&PC Dramatic slippery slope cautions regarding the most

vulnerable have not been borne out in Oregon; some concerns in the Netherlands but

PAD is about patient autonomy not intractable symptoms in terminal and EOL care

Profound consequences for society and health care professionals generally

Significant consequences for hospice & palliative care, in particular PAD medicalizes dying; provides a technical ‘fix’ for

suffering Polarizes staff into those pro and con; affects “the team” Does PC become the death specialty?