medical aid in dying - developing a framework plenary #1 delivering medical aid in dying: delivering...

Medical Aid In Dying -Developing a Framework

Plenary #1 Delivering Medical Aid In Dying:

The Big Issues

Temmy Latner Centre for Palliative Care1

October 27, 2015

Sandy Buchman MD CCFP FCFP


Objectives• To offer the practicing physician’s

perspective on physician-assisted dying (PAD)

• To offer some suggestions on designing a legal framework to support the choice of physicians to participate

• To comment on certain aspects of proposed legislation such as education, language and organ transplantation after PAD


“Physician-Centric”What kind of legislative framework will it

take to…

• Allow me to comfortably agree to participate in physician assisted dying?

• Persuade a new physician to participate?• Allow me to remain involved for the

duration of my career?• Allow a sufficient number of physicians

to participate to meet society’s needs for this service?


PAD: Effects on the Living?


PAD: Impact on Physicians

Emotions:• uncertainty, loss, fear of technical

failings• Impact of participation on one’s

reputation (both pro and con) with one’s colleagues (intra and interprofessional), family and community

• lack of clarity re my duty to my patient – duties to refer and duties to inform


PAD: Impact on Physicians

Trust/Therapeutic Alliance: • Is there trust lost between doctor

and patient (those that don’t want PAD?) – If I become known as an MD who undertake PAD…– how will that effect their trust of

me as their physician? – How will their families’ regard me?

Will trust be eroded?


Legislation helps…• Permits “someone” to watch over

you• Enhances trust when followed

conscientiously• Should the legislation place all

the burden and responsibility on the individual physician?–Suggest that the legislation

could make the decision to become involved a ‘team” responsibility


Assessment:Exploring the Request

Patient factors:

• Formal evaluation of cognitive status/capacity

• Formal evaluation for any psychiatric condition that may impair capacity or autonomy

• Patient’s request will be made known to the patient’s SDM

• No evidence or suspicion of patient coercion o manipulation to promote the request for PAD


Assessment:Exploring the Request

Disease related factors:

• Treatment has been offered either previously or currently and acknowledged by the patient

• Rejection of treatment must be documented


Processing the Request• 2nd opinion from another MD is

mandatory for each request within a reasonable time period (1-2 weeks)

• 2nd physician uses the same template as the first in all domains

Centre for Palliative Care 11

Provision of Assisted Death• The patient will review with the

physician the procedure for provision of assisted death

• Sign (witnessed by a third party) consent form indicating agreement

• Legislation must address the involvement of other professionals (Nurses, NPs, Pharmacists)

• RN and MD (or their substitutes) willing to participate must be easily accessible/available if needed


Provision of Assisted Death• There can no ingestion of lethal

medication unless both RN and MD available/accessible

• MD must remain accessible until the patient expires

• If hastened death is lethal provision, the MD administers the medication and remains until the patient’s death

• Formal documentation and reporting to oversight body is mandatory & described by regulation


Pronouncement• Coroner to be notified• Cause of death on death

certificates to be determined: disease or lethal ingestion or injection


EducationFor all practicing physicians who intend to provide PAD as well as and all trainees:• Competencies/Learning Objectives:

– Consider ethics around PAD– Understand the legal and regulatory frameworks

for PAD– Understand the process of referral, assessment

and delivery of PAD – Develop competency in discussing options at the

end of life, including PAD– Understand pharmacology of PAD– Understand how to deal with complications of PAD

For all those who will not participate, basic training in “how to have the conversation” regarding a duty to inform is recommended

Temmy Latner Centre for Palliative Care

Organ Transplant after PAD

• Potential solution to the organ scarcity problem although numbers likely to be small

• Must be addressed in any legislative framework

• Must insist that a physician who facilitates in any way the provision of PAD will not benefit from the death of the patient*

15 * Swiss Penal Code


Language• Palliative care MDs provide medical aid in dying daily• Terms assisted dying, physician assisted dying and

assisted death are imprecise• Patients may believe that assisted death = hastened

death• Suggest:

– Patient administered, physician-hastened death to replace physician assisted suicide

– Physician administered, physician-hastened death to replace euthanasia

– Physician-hastened death to replace assisted dying

– Medically-prescribed death could be an option if other professions are involvedCanadian Society of Palliative care Physicians.

http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf Accessed October 24, 2015

http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf





Summary• Consider the humanity of and impact upon

any physician who agrees to participate in PAD

• Design a legislative framework to support and sustain the physician’s decision to participate

• Describe a clear PAD process to be included in the legislative framework from the initial request to the provision of PAD to the processes after death

• Obligatory training in managing a request for PAD, organ transplantation after PAD and attention to language need to be considered

********

medical aid in dying - developing a framework plenary #1 delivering medical aid in dying: delivering...

Documents