Physician assisted death challenges for hospice and palliative care
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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. Historical Perspectives on Physician Assisted Death (PAD).

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Physician Assisted Death: Challenges for Hospice and Palliative Care

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Physician assisted death challenges for hospice and palliative care

Physician Assisted Death: Challenges for Hospice and Palliative Care

Nuala 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

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

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

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

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”


Some arguments for physician assisted suicide

Some Arguments For PhysicianAssisted Suicide

  • 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 against physician assisted death

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

Assisted Death: Special Challenges for Hospice and Palliative Care


Hospice palliative care h pc implications of the legalization of pad

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

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 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

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

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

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%)

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


Requests for ad a systematic review hudson et al palliative medicine 2006 20 693 701

Requests for AD-A Systematic ReviewHudson 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

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


Slippery slopes

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 slopes1

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

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

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

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?


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