A healthy death

TH - PHSPTrevor Hancock is a professor and senior scholar at the University of Victoria’s school of public health and social policy

 

When Canada’s Supreme Court struck down the law prohibiting the provision of assistance to someone committing suicide in February last year, I wrote a column welcoming this ruling. That led to an invitation to address the Annual Conference of the BC Palliative Care and Hospice Association in May 2015 on the topic of  ‘healthy death’.

More recently, I have collaborated with Dr. Douglas McGregor, Medical Director of the Victoria Hospice, in conversations with hospice staff and volunteers from Victoria and across Vancouver Island. Our topic was physician-assisted death (PAD) and the dilemmas this poses for the people who work in hospice and palliative care.

I am very clear that a ‘healthy death’ is one that enables someone to have control over their way of death. So for me, it is about my right to autonomy in selecting my own time and way of death, should I so choose. But I also respect and support the autonomy of physicians to decide whether or not they participate in PAD.

This is no different from the right of gynaecologists to refuse to do abortions, which does not prevent abortions from happening. But I have learned that palliative care physicians, on the whole, have some serious concerns with the issue of PAD, and most currently seem unwilling to participate in the process. They fear that providing PAD in the hospice will lead to people seeing the hospice as a place where people are killed, instead of a place where people can receive compassionate care to allow natural death.

This presents a dilemma, because they see themselves - and they are seen, rightly - as the experts in compassionate care for the dying. But society - through public opinion, the courts and, soon, through Parliament - has expanded the concept; compassionate care is now seen to include PAD. And as I stated in one of our discussions with palliative care staff and volunteers, , when it comes to PAD provided in a compassionate way: If not you, then who? If not in the hospice, then where?

At least for some palliative care physicians, and other physicians for that matter, providing PAD will be simply a logical extension of the work they already do, or perhaps of their own personal wishes. So this would be a place to start; surely providers who would wish for themselves the option of PAD would be the logical providers of such care for others.

As to ‘where’, for many, a healthy death would be at home, surrounded by one’s loved ones. In fact, most deaths in Island Health do not occur in hospices, but at home (20%), or in a residential care facility (another 28%), which of course is also one’s home. Only about 1 in 8 deaths (13%) occur in a hospice in this region, with a further 36% in hospitals.

So the main care providers involved in PAD are likely to be the existing staff providing palliative home care and perhaps in some cases family physicians who are in favour of PAD and are appropriately trained.

The first challenge for our palliative care providers will be when a patient in a hospice requests PAD. It is difficult, if not impossible, to imagine that the hospice and its medical staff will require that person to be moved elsewhere.

Note that we are not talking about huge numbers here. Even in the Netherlands and Belgium, where it has become normalized, only about 3.5 percent of deaths involve PAD. Since the CRD has about 3,200 deaths a year, this would amount to a bit over 100 PADs a year in this region, or two a week. At least in the early stages, I suspect it would be less than that, perhaps one a week. That should be manageable, especially as many will not occur in a hospice or hospital.

I suspect that in time, palliative care physicians and the palliative care system as a whole will adjust to this new reality, just as has been the case for abortion services. We need to support them as they work through this change, give them the respect they deserve for the difficult work they do, and show compassion for them as they struggle with this ethical dilemma.

Editor's note: This blog was originally published as a regular column in the Times Colonist

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