MAiD in Canada: A Dying Shame

The Palliative Palate

By Anonymed (an anonymous Canadian Doctor)

Death has this much to be said for it: You don’t have to get out of bed for it. Wherever you happen to be. They bring it to you - free 

 -  Sir Kingsley Amis

Of all the world’s creatures, only humans take pains to easen death. While a handful of other animals are thought to experience and express grief, only homo sapiens anticipates, prepares for, and fears the end. 

On one hand, Medical Assistance in Dying (MAiD) - as euthanasia is now euphemistically known - is a continuation of the age-old effort to preserve human dignity during the final stage that awaits us all. On the other, it represents a seismic shift in the way society looks at death and dying, as well as the way in which physicians are meant to treat it.

For me, any discussion of the topic is incomplete without first understanding the niche it purportedly fills. Death and dying are of course ever-present in medicine, and how best to manage them has evolved over centuries. The tradition of the Hospice (a place of care for the desperate and dying) can be traced to the Roman Empire, and the incorporation of physician care for the dying goes at least as far back as medieval Christendom. But it wasn’t until the increased specialization of the profession in the 20th and 21st centuries that medicine produced a dedicated field for the management of death, now referred to as Palliative Care and Symptom Management.

Palliative Care is now a Royal College specialty (which means it takes five years of residency to qualify) and deservedly so. Where once the dying among us were limited to monk and Sister-led care - the kind of high-compassion, low-expertise medicine for which figures like Mother Teresa became famous - modern medicine has invested in a highly evidence-based, holistic specialty that aims to address all aspects of patients’ health in their final stage of life. 

Care of the terminally ill is no longer viewed as a passive enterprise and palliative wards are not places where patients just go to die - they are actively managed and treated with the dignity they deserve. Palliative care teams often treat patients in their homes to improve comfort as the end approaches; multidisciplinary teams are the norm, here more than elsewhere; outpatient social workers and nursing care are often available around the clock for those not in hospital; and some facilities even hire "legacy workers" to aid terminally ill patients (and their families) in framing and "authoring" their lives.

Pharmacologically too, things have improved. Not that we didn't understand nausea and constipation and anxiety before, but we are more attuned to them and have more versatile ways of administering medications (such as intranasal and subcutaneous forms of drugs only previously available by oral or intravenous routes). We have also, crucially for our purposes, shaken off the notion that quantity (and not quality) of life is the ultimate goal of medical intervention. 

Given that we already have a dedicated end-of-life specialty, this would seem like the best place in the healthcare system to incorporate MAiD in a manner that would assuage public concerns and facilitate continuity of care. Palliative care physicians know the patients, they know the pitfalls, they know how to navigate the scheming family member who just came back into the picture because they want a cut of granddad’s priceless and pawnable baseball card collection, and they know the drugs. Most importantly, they know how to talk to people about dying. Sure, lots of doctors do, but trust me when I tell you that it takes practice to get good at it, and this skill can make all the difference in relieving anxiety and suffering for patients and their families.

The problem is, for all the apparent seamlessness with which MAiD could potentially be integrated into palliative care, it is not, because palliative care physicians, historically at least, do not support MAiD. 

Working on a palliative care service is a unique experience. The clinical approach is very different from other patient care. Because the focus is largely on symptom control, so much of the busy work of medicine is just not done. No labs, no imaging, no vitals, no IVs, no monitors (except perhaps pulse oximetry), nothing. In order to be admitted to a palliative care ward, patients must have already decided to forgo “heroic measures” in the event that things turn dire - no CPR, no intubation, no antibiotics, not even fluids (which tend to worsen the dying process). The result is a much greater reliance on assessment of function, which can be difficult when patients are approaching the end - they get depressed, anxious, nauseous, delirious, constipated, and have reactions to the high doses of opiates often needed to control pain. In addition, they are expected to decline and so distinguishing natural disease course from something to be managed is complicated, and even harder to explain to patients and their families. 

All of this gives palliative care physicians a unique set of skills. Once the emphasis on curing disease has been dispensed with in favour of controlling symptoms and supporting patients and their families, the mindset changes. The focus shifts to ensuring a good death and quality of remaining life. If there is an art to medicine, it is in such fields where it is found.

A critique of those opposed to MAiD has always been their alleged lack of empathy for those with, as the Supreme Court put it, “enduring suffering.” It is said they are insufficiently attuned to the suffering that patients go through - that if only they had to see the indignity and pain and anxiety suffered by so many, they would support MAiD too. But this surely cannot be said of palliative care physicians. They are the most attuned. They see people at their most vulnerable, enduring the most intense suffering. None will have done this job for long without having seen the whole spectrum of death and dying, from noble to tragic to down-right ugly. What’s more, while they refrain from actions that hasten death, palliative physicians understand that proper symptom control may require significant intervention - such as palliative sedation, whereby patients are rendered unconscious while nature takes its course. And yet, not only is MAiD not typically offered as part of the ‘basket’ of palliative care services, palliative care physicians, as a group, tend to oppose its legalization altogether. With all of this compassion and intimate experience with suffering on board, why do they not support MAiD? 

From the Canadian Society of Palliative Care Physicians:

MAiD is not part of hospice palliative care; it is not an “extension” of palliative care, nor is it one of the tools “in the palliative care basket”. National and international hospice palliative care organizations are unified in the position that MAiD is not part of the practice of hospice palliative care...Hospice palliative care and MAiD substantially differ in multiple areas including in philosophy, intention and approach. Hospice palliative care focuses on improving quality of life and symptom management through holistic person-centered care for those living with life threatening conditions. Hospice palliative care sees dying as a normal part of life and helps people to live and die well. Hospice palliative care does not seek to hasten death or intentionally end life. In MAiD, however, the intention is to address suffering by ending life through the administration of a lethal dose of drugs at an eligible person’s request.

Fundamentally theirs is a philosophical disagreement - about the ethos of medicine in general, and about the role of intent in particular. While palliative care views quality of life as an important variable, and thus accepts that proper palliation may render patients effectively incapacitated, it draws a deep dark line in the sand between natural death as a secondary outcome of proper symptom management and the intentional truncation of life. As we will discuss next week, the premise underlying MAiD is that the distinction between intent to kill and intent to treat (with the side effect of natural death) is one without much of a difference.

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Thanks for reading. For more from this author, read The Queen’s Stakes

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