Physician Assisted Death: Challenges for Hospice and Palliative Care Nuala Kenny, OC, MD, FRCP(C) Professor Emeritus Department of Bioethics Dalhousie University Ethics & Health Policy Advisor Catholic Health Alliance of Canada
Jan 11, 2016
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?