Reflecting on end-of-life care

In August I attended the Canadian Medical Association (CMA) Annual Meeting and General Council. There were several important issues discussed during the meeting but the one that stood out for most attendees was that of physician-assisted death and end-of-life care. Over the past year, the CMA held a number of town hall meetings for physicians and the public across the country and produced a discussion paper on the subject.¹ In June, the CFPC also held a symposium on end-of-life care that brought together a group of physicians and other experts to discuss this issue and help guide our College. Further, Dr Lemire wrote about it in her Cumulative Profile in the September issue.²

When listening to stories of physicians’ end-of-life care experiences, comments from the guest speakers and delegates at the General Council, and other discussions on dying, I am always drawn to reflect on my own experiences with death as a physician. There have been many, but a few stand out.

My earliest experiences, coming in at the last moments of a person’s life and leaving soon after, were as a student and first-year resident at a hospital, where I was a member and, subsequently, a leader of the resuscitation team. I also still vividly remember the first time I had to go to someone’s home to pronounce an expected death. When I was a resident working on call at night, I had to pronounce deaths in the hospital. A few faces remain with me, but in most cases, I was just the physician who arrived after the person had died, without any particular connection to the patient or family.

My experience as a practising family physician has been considerably different. I have sat at the bedsides of my patients while they decided with their families to stop all life-sustaining interventions. I have sat with new parents as they faced the extreme prematurity and lethal congenital anomalies of their infants. I have been part of a team that assisted women with delivering their stillborn infants. I have called my patients’ family members to the hospital as their loved ones were dying and sat with them while they grieved. I have also listened when my patients talked about what they wanted for the remainder of their lives and what their hopes were for their families after they were gone. Further, I have been fortunate to be part of a palliative care system in my community that supports the needs of my patients as they die. In his speech upon taking office, Dr Chris Simpson, the current president of the CMA, stated that how you die in Canada depends on where you live.³ In my role as President, I have spoken to physicians from across the country about palliative care services in their communities and I echo his statement.

All of this reminds me of what a privilege it is to be part of the lives of my patients and their families at such a critical juncture. Joy, sorrow, fear, hope, anger, acceptance, confusion, relief—there are so many emotions, yet each person and family has a different way of facing death. Each time one of my patients dies I confront my own beliefs about life and death. Every death has taught me something about humanity, myself, and what it means to be a physician.

There are many more discussions to have as physicians and as a society about the end of life. Some of these discussions might be resolved by legislation or legal decisions that will have a direct effect on our profession. For some physicians these issues are in black and white and for others they are in many shades of gray. I do not believe that as individuals we will ever have the same opinions about the issues that we have been discussing as a profession, but I am glad we are having these important conversations. My hope is that whatever the decisions, discussing death as a society will help our patients find it easier to discuss end-of-life care with their loved ones and health care providers. While we as physicians are shaped by participating in the lives of our patients, we are part of the end of our patients’ lives because we have been invited to work with them, not decide for them.

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