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

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)

  • 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”

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

  • 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

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 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

  • 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

  • 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?

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