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Question: Can you describe a “typical” assisted death? I would like to know exactly what is given to the patient and does it involve any suffering.
Answer: The federal Government is still in the process of drafting assisted-dying legislation. It has until June 6th to enact a new law that complies with a Supreme Court of Canada ruling in 2015, which struck down the country’s ban on doctor-assisted death.
So, we can’t yet say with certainty what type of assisted death will be available to a majority of Canadians (Quebec adopted its own protocol in December).
But it will likely follow the examples set in other places where medically assisted dying has been permitted for many years. There are essentially two different approaches:
- In the Netherlands, a physician administers a combination of drugs either through an IV needle or by mouth. (The Quebec approach, in which a physician must be present, is partly based on the Netherlands model.)
- In the U.S. state of Oregon, a doctor writes a prescription for the patient who can then pick up the oral medication at a local pharmacy. The patient is basically in control and decides when and where to take the lethal dose (100 or more capsules) that is mixed into a sweet drink such as juice, to mask the bitter taste. The patient is usually instructed to also take an anti-nausea medication beforehand to prevent vomiting up the toxic drink.
An expert panel, appointed by the provincial and territorial governments, has recommended that Canadians be given both options.
“It should be the patient’s choice,” says Maureen Taylor, a physician assistant and co-chair of the advisory group.
Taylor is the widow of Dr. Donald Low, a highly respected microbiologist who made a passionate appeal for assisted death before he succumbed to brain cancer in 2013.
“I know for Don, we didn’t want anyone else there when he died,” says Taylor. “He would have been happy to take the medication at home.”
A special joint parliamentary committee, made up of ten Members of Parliament and five Senators, also produced a list of recommendations related to eligibility and access to medical assistance in dying.
However, it did not deal with the specifics of how the drugs should be administered, leaving those details to the medical profession, and the provincial and territorial governments which are constitutionally responsible for delivering health care.
“We have left that somewhat open,” says Liberal MP Rob Oliphant, co-chair of the committee. “We believe that it should be a matter of clinical practice guidelines with the best interest of the patient in mind.”
Oliphant hopes that all Canadians will be offered the same choices, rather than having a “patchwork” of different policies across the country. Quebec, in particular, might be out of step with the other provinces. “We are recommending that there be fruitful discussions among the provinces and the federal government to find a way of having a pan-Canadian approach,” says Oliphant.
But regardless of what is permitted by law, the method used to hasten death may at least initially hinge on drug access.
Right now, the main oral medications used for assisted death in Oregon – secobarbital and pentobarbital – aren’t available in Canada, says Dr. Ellen Wiebe, a clinical professor in the department of medicine at the University of British Columbia.
Other oral medications could be used, but the alternatives can take a relatively long time to bring about death – four to ten hours. By contrast, the IV drugs lead to death in about 15 to 20 minutes.
“I strongly believe we need to have access to good oral medications which patients can take themselves,” says Dr. Wiebe. “This is a time in one’s life – the very end – when you would like to get rid of the doctors and just have your loved ones around.”
But until better oral drugs are readily available, Dr. Wiebe expects most patients will opt for the IV drugs injected by a health-care provider. (Even in the United States, drug access has become a real concern because of recent steep price hikes for some of the oral medications.)
Dr. Wiebe is one of the first Canadian physicians to take part in a medically assisted death. She attended to a Calgary woman who had obtained court approval in February for an assisted death – ahead of the new federal legislation being passed. The woman suffered from advanced amyotrophic lateral sclerosis (ALS), a neuromuscular disease that had left her almost completely paralyzed.
Dr. Wiebe travelled to The Netherlands earlier this year to study first hand how Dutch doctors carry out assisted dying. “Dutch doctors have been doing it for 30 years. They know how to do it well.” Most of their patients – 90% – select the IV medicatrions.
The Dutch IV protocol involves the injection of three separate drugs:
- The first medication is a sedative that relaxes the patient and induces sleep.
- The second drug puts the patient into a coma and eliminates any reflexive movements.
- The third drug is a neuromuscular block that paralyses the muscles, including those involved in breathing, thereby resulting in death.
“For the patients, they just go to sleep and won’t wake up,” explains Dr. Wiebe.
In some ways, it’s a more peaceful passing than what might happen naturally.
Dr. Wiebe points out that terminally ill patients often slip into a coma when they are dying and it may take over a day before the heart stops.
“With a planned death, it is much easier on the family members because it takes minutes instead of hours.”
The goal of a medically assisted death, she adds, is to the make the patient feel and appear comfortable. So, the IV medications work in a way that eliminates any gasping or shaking that might upset the loved ones sitting at the bedside.
Dr. Wiebe expects that the federal legislation will stipulate that two doctors must agree that a patient meets the criteria for an assisted death before it can take place. The Supreme Court has ruled that competent adults with a “grievous and irremediable medical condition” have the legal right to request assisted death.
Both the parliamentary and the provincial-territorial committees recommended that other health professionals – such as nurse practitioners and physician assistants – should be legally permitted to administer the lethal doses.
“We just don’t have the supply of doctors to be able to provide a physician on-site in every remote area,” says Taylor. “That’s why we’re recommending that others, acting under the supervision of a physician, should be able to carry this out.”
Oliphant, who has been a United Church minister for 30 years, believes only a small fraction of Canadians will eventually opt for an assisted death.
Yet simply having that choice available “will provide peace of mind” says Oliphant, who has been at the bedside of many dying patients in his role as a minister.
“The thought of the pain is very, very worrisome to some people. They want to have the option of assisted death” even though they may not follow through in the end, he says.
That’s certainly the pattern that has emerged in other places where assisted death is legal. Far more people discuss it with their doctors than act on it. In The Netherlands, for instance, only 3% of people rely on a doctor to hasten death. “The reality of the journey is usually better than they imagined,” says Oliphant.
Read more: A full Q&A between Paul Taylor and Rob Oliphant is available here.
Paul Taylor, Sunnybrook’s Patient Navigation Advisor, provides advice and answers questions from patients and their families. His blog, Personal Health Navigator, is reprinted on Healthy Debate with the kind permission of Sunnybrook Health Sciences Centre. Follow Paul on Twitter @epaultaylor.