Medical aid in dying

Between the idea

And the reality

Between the motion

And the act

Falls the Shadow

T.S.Eliot The Hollow Men

Most people in Canada do not get to die as they would like-at home, with loved ones and without suffering. Dr Ladouceur's editorial is one example of: 1) the present quality of end of life care; and 2) the confusion of terms surrounding same - euthanasia, physician assisted death, physician hastened death, palliative care and in his article, medical assistance in dying (MAID).

What morally differentiates these terms is the ethic of intention, of beneficence and self-determination. All terms relate to relief of suffering. Only palliative care is a continuum of ongoing care managed by the patient, family and caregivers. WHO Definition of Palliative Care (excerpt):

Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life- threatening illness, through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other problems, physical, psychosocial and spiritual.

In the case example given: 1) the patient died suffering and his family suffered; and 2) the discussion of MAID is sadly ironic because the principal reason for requesting the means to one's own death, is the fear of suffering.

Nonetheless, the acronym MAID is misleading: it is not assisted dying, but rather assisted suicide. Physicians do assist in the process of dying- it is called relief of suffering. That said, physicians relieve suffering in the process of saving lives as well. However in the instance given, death was imminent. The patient's daughters wanted the suffering to end and to achieve this they were willing to accept the risk of death for the benefit of relief. Thus, they implied an informed consent along with the acceptance of the double effect of palliative sedation. This is morally acceptable albeit perhaps for some morally distressing. Their focus was on the suffering, while the physician's was on the dying.

Suffering and dying need to be distinguished. When death is imminent and suffering apparent, this is not the time for moral confusion or stances on middle ground. Unconditional compassion for the patient and loved ones will provide creative solutions to achieve a peaceful and dignified death.

There is only one chance to get end of life care right. In Canada, most people die in hospital (more than 60%) and few receive palliative care service (less than 30%). This is not how we wish to die. To that end, there are calls to action:

1) How to improve palliative care in Canada: A call to action for federal, provincial, territorial, regional and local decision-makers, from the Canadian Society of Palliative Care Physicians November 2016.

2) Private member's Bill C- 277 to effect universal access to palliative care.

3) Palliative care education is expanding. In particular, the College of Family Physicians has CCFP-Certificate of Added Competency in Palliative Care (430 practitioners across Canada in 2016) local initiatives, e.g., India, north Kerala. Neighborhood Network in Palliative Care has more than 60 units covering a population of more than 12 million, and is probably the largest community-owned PC network in the world

In summary, Dame Saunders, the physician pioneer (1967) for hospice care, best explains the philosophy for end of life care:

A patient, wherever he may be, should expect the same analytical attention to terminal suffering as he received for the original diagnosis and treatment of his condition. The aim is no longer a cure, but the chance of living to his fullest potential in physical ease and activity with the assurance of personal relationships until he dies.

DM Westerhoff

Conflict of Interest:

None declared