Nurses Wrestling With the Moral Uncertainties of MAiD

Barbara Pesut and Sally Thorne
Impact Ethics
Originally posted October 23, 2019

Have you tried to imagine what it is like to be the healthcare provider who provides medical assistance in dying (MAiD)? What would it feel like to go into a strange home, to greet a patient and family, to start an intravenous line, to deliver the medications that rapidly cause death, and then to bring some sort of closure before leaving? Although there has been a great deal of attention paid to the regulation of MAiD, and its accessibility to the Canadian population, we have heard relatively little about the moral experiences of the healthcare providers at the forefront of providing this service. That is surprising in light of the fact that all but 6 of the 6,749 MAiD deaths in Canada that occurred between December 10, 2015 and October 31, 2018 were administered by physicians or nurse practitioners.

In a recent study we interviewed 59 nurses from across Canada, who had diverse experiences with participating in, or choosing not to participate in, the MAiD process. Canada is the first country to allow nurse practitioners to act as both MAiD assessors and providers. Canadian registered nurses also play a key role in providing care to patients and families considering, planning for, or receiving MAiD. We learned a lot about the experiences of being involved in MAiD and about the type of wrestling with moral uncertainty that the involvement can entail. Nurses worked hard to make sense of this radical new end-of-life option. Making sense required some soul searching, some important conversations, and in some cases, encounters with the procedure itself.

Encounters with MAiD were inevitably deeply impactful. Some participants described an emotional overload that was unanticipated and didn’t necessarily fade over time. Others described a deep sense of compassion and purpose—a sense of beauty. Still others described an accumulating sense of distress, a rising tide that they didn’t necessarily know how to deal with. This was particularly true for those nurses who worked alone on multiple cases because they were the sole person willing to provide MAiD. Even those who had experienced MAiD only as observers described an emotional climate within the care environment that was far-reaching.

The info is here.

Number of Canadians choosing medically assisted death jumps 30%

Kathleen Harris
www.cbc.ca
Originally posted June 21, 2018

There were 1,523 medically assisted deaths in Canada in the last six-month reporting period — a nearly 30 per cent increase over the previous six months.

Cancer was the most common underlying medical condition in reported assisted death cases, cited in about 65 per cent of all medically assisted deaths, according to the report from Health Canada.

Using data from Statistics Canada, the report shows medically assisted deaths accounted for 1.07 per cent of all deaths in the country over those six months. That is consistent with reports from other countries that have assisted death regimes, where the figure ranges from 0.3 to four per cent.

The information is here.

Suicide Is Not The Same As "Physician Aid In Dying"

American Association of Suicidology
Suicide Is Not The Same As "Physician Aid In Dying"
Approved October 30, 2017

Executive summary 

The American Association of Suicidology recognizes that the practice of physician aid in dying, also called physician assisted suicide, Death with Dignity, and medical aid in dying, is distinct from the behavior that has been traditionally and ordinarily described as “suicide,” the tragic event our organization works so hard to prevent. Although there may be overlap between the two categories, legal physician assisted deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.

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Conclusion 

In general, suicide and physician aid in dying are conceptually, medically, and legally different phenomena, with an undetermined amount of overlap between these two categories. The American Association of Suicidology is dedicated to preventing suicide, but this has no bearing on the reflective, anticipated death a physician may legally help a dying patient facilitate, whether called physician-assisted suicide, Death with Dignity, physician assisted dying, or medical aid in dying. In fact, we believe that the term “physician-assisted suicide” in itself constitutes a critical reason why these distinct death categories are so often conflated, and should be deleted from use. Such deaths should not be considered to be cases of suicide and are therefore a matter outside the central focus of the AAS.

The full document is here.

Has Physician-Assisted Death Become the “Good Death?”

Franklin G. Miller
The Hastings Center
Originally published May 30, 2017

“Death with dignity” for the past 40 years has meant, for many people, avoiding unwanted medical technology and dying in a hospital.  A “natural” death at home or in a hospice facility has been the goal.   During the last 20 years, physician-assisted suicide has been legalized for terminally ill patients in several states of the United States, and recently “medical assistance in dying,” which also includes active euthanasia, has become legal in Canada.  How should we think about what constitutes a good death now?

There are signs of a cultural shift, in which physician-assisted death is not just a permitted choice by which individuals can control the timing and circumstances of their death but is taken as a model of the good death.  A recent lengthy front page article in the New York Times recounts a case of physician-assisted death in Canada in a way that strongly suggests that a planned, orchestrated death is the ideal way to die.  While I have long supported a legal option of physician-assisted suicide for the terminally ill, I believe that this cultural shift deserves critical scrutiny.

The article is here.

California doctor opens end-of-life clinic

by Michael Cook
BioEdge.org
Originally published June 11, 2016

California’s right-to-die law was rolled out this week and at least one doctor immediately opened up a dedicated assisted suicide clinic in San Francisco.

At Bay Area End of Life Options, Dr Lonny Shavelson, a well-known advocate of assisted suicide, will advise people who are wondering whether they ought to end their lives.

Dr Shavelson denies that he will be operating a drive-in suicide service. He says that he wants to work with patients to explore all the legal and therapeutic options. "When somebody says to a physician that they want to talk about the End of Life Option Act and says, 'Can you give me a prescription that will end my life?' I want them to tell me why," he told the San Jose Mercury. "A major goal of physicians is to make this (prescription) not happen."

His fees will be US$200 for an initial consultation plus $1800 if the patient is qualified and wishes to continue.

The article is here.

Dignity, Politics, and Medical Assistance in Dying

by Harry Critchley
Impact Ethics
Originally published June 6, 2016

Here is an excerpt:

A common problem with both of these approaches to understanding dignity, however, is the underlying assumption that dignity is best understood from a theoretical perspective. Another, more fruitful approach might be to examine the meaning of dignity with reference to its use in public discourse. On this view, to determine what dignity is requires that we ask what appeals to dignity are intended to do. Dignity is not only, or even primarily, appealed to in the solitude of philosophical contemplation, but rather in the company of others. Regardless of whether we understand dignity as sanctity of life or as autonomy, its emergence and acknowledgement in the political arena is an achievement not wholly dependent on its theoretical grounding.

The article is here.

Panelists Debate Morality Of Assisted Suicide Bill

By Jenna Rudolfsky
The Cornell Daily Sun
Originally posted April 18, 2016

Panelists from the Cornell Law School hosted a discussion entitled “Death with Dignity” to debate the controversial issue of assisted suicide and pending New York state legislation last Thursday.

If the “Death with Dignity” bill passes, New York will become the sixth state to allow terminally ill patients to end their own lives with prescribed lethal medication, according to MSNBC.

Panelist Prof. Daryl Bem, psychology, whose wife committed assisted suicide, discussed her struggles with Alzheimer’s disease in explaining why he is in favor of assisted suicide.

The article is here.

A Time to Fly and a Time to Die: Suicide Tourism and Assisted Dying in Australia Considered

Hadeel Al-Alosi
UNSW Law Research Paper No. 2016-04
January 8, 2016

Abstract:    

Recently, a series of high-profile court cases have led the Director of Public Prosecution in the United Kingdom to publish a policy clarifying the exercise of its discretion in assisted suicide. Importantly, the experience in the United Kingdom serves as a timely reminder that Australia too should formulate its own guideline that detail how prosecutorial discretion will be exercised in cases of assisted suicide. This is especially given the fact that many Australian citizens are travelling to jurisdictions where assistance in dying is legal. Any policy should not, however, distract from addressing law reform on voluntary euthanasia. Australian legislators should be consulting with the public in order to represent the opinion of the majority. Nevertheless, any future policy and law reform implemented should provide adequate safeguards and be guided by the principle of individual autonomy.

The paper is here.

The History of the Euthanasia Movement

BY Anna Hiatt
JSTOR
Originally published January 6, 2016

The idea that death should be merciful is not new. When a person is gravely wounded or terminally ill, when death is inevitable, and the suffering is so great that living no longer brings any joy to the person, it is understandable that he or she may wish to die. In “Two Pioneers of Euthanasia Around 1800,” Michael Stolberg cites accounts of people pulling on the legs of those who had been hanged, but had not yet died, to hasten their deaths. He mentions also Apologie, the autobiography of a French surgeon named Ambroise Paré who happened upon three gravely wounded soldiers. An uninjured soldier asked the surgeon if they would live, to which he responded they would not. The uninjured soldier proceeded to slit their throats.

The invention and widespread use of morphine in the 19th century to treat, and then to kill, pain led to the belief that a less painful dying process was possible, Giza Lopes writes in her book Dying With Dignity: A Legal Approach to Assisted Death.

The article is here.

Opponents fail to derail the state's right-to-die measure, but they may yet try again in court

By The Times Editorial Board
The Los Angeles Times
Originally posted January 7, 2016

Here is an excerpt:

The group behind the referendum attempt, known as Seniors Against Suicide, says it is now contemplating a lawsuit to stop the law's implementation. The law is set to go into effect 90 days after the state Legislature concludes the still-open special session on healthcare.

We respect the law's opponents, including the Roman Catholic Church and some disability-rights advocates; they waged a passionate battle — both moral and practical — against it. But we don't share their fears. There is no evidence that a law this narrow would lead uncaring health insurers or family members to coerce sick patients to kill themselves in order to save on medical costs.

To the contrary, two decades of experience with Oregon's landmark Death with Dignity Act suggests that it will be used sparingly. In the first 17 years, just 1,327 people in Oregon requested a life-ending prescription from a doctor. More than a third of them then chose not to use the prescription.

The article is here.

Who Should Have The Right To Die?

By Nerdwriter
Originally posted October 28, 2015

Doctor-assisted suicide continues to be hotly debated in the United States, but the ideas – and specifically the words – used to support it have evolved in fascinating ways. Over nearly a century, there has been a shift away from terms related to death towards a focus on autonomy and dignity, drawing in no small part on the ideas of the 19th-century English philosopher John Stuart Mill.

Your Right to Die Isn’t Enough

By Elizabeth Stoker Bruenig
The New Republic
Originally published July 15, 2015

Here is an excerpt:

Some opponents of assisted suicide legislation are concerned that, with assisted suicide on the table, exhausted doctors and cash-strapped families might coerce ill family members into taking this cheap, quick way out rather than suffering through further treatments and payments for terminal illness. Others worry that legal assisted suicide will transform culture in such a way that the option to die will eventually be interpreted as an obligation to do so after a certain point, creating a slippery slope from legal to de-facto compulsory. Still others fear that euthanasia advocates don’t appropriately take into account the possibility of spontaneous remission, and worry that readiness to end the lives of terminally ill patients would foreclose the possibility of recovery for those with the potential for it, however slim.

There is little evidence that legal euthanasia contributes to the coercion of the poor, and numbers on spontaneous remission can usually be adduced for any given terminal disease, which helps prevent the what-if objection from gaining much traction. Yet there is reason to worry about a slippery slope forming between the legal but rare option of euthanasia for the terminally ill and the haphazard elective suicide of persons with no real physical illness. At this moment, for example, a 24-year-old Belgian woman is awaiting assisted suicide for no reason other than her unhappiness. She won’t be the first: a friend of hers who also suffered from depression was euthanized for that condition less than two years ago, following in the footsteps of numerous people with sad life experiences or momentary shocks who, thanks to Belgian law, sought death instead of treatment.

The entire article is here.

Quebec doctors to get standard euthanasia kits

Sharon Kirkey
The Montreal Gazette
Published on 08.27.2015

Quebec doctors will soon be given standardized kits with which to end the lives of patients seeking euthanasia — including drugs to calm the nerves and stop the breathing  — along with detailed instructions as the province prepares to usher in legalized aid in dying.

The Collège des médecins du Québec has developed a new guideline for doctors unlike any in the history of Canadian medicine: a step-by-step guide to follow before, during and after administering euthanasia to an eligible patient, including the type of drugs to be used, the dose, the injection site and what to do in the event of complications.

The guideline, which was developed in collaboration with the Order of Pharmacists of Quebec and the Order of Nurses of Quebec, will be available to doctors, nurses and other health professionals on a secure area of the college’s website. “We don’t want these recipes made too easily available to everyone,” college secretary Dr. Yves Robert told the Post.

In December, Quebec will become the first jurisdiction in the country to allow competent adults experiencing intolerable suffering at the end of life to request “medical aid in dying.”

The entire article is here.

Euthanasia cases more than double in northern Belgium

By Raf Casert
Associated Press
Originally published March 17, 2015

Almost one in 20 people in northern Belgium died using euthanasia in 2013, more than doubling the numbers in six years, a study released Tuesday showed.

The universities of Ghent and Brussels found that since euthanasia was legalized in 2002, the acceptance of ending a life at the patient’s request has greatly increased. While a 2007 survey showed only 1.9 percent of deaths from euthanasia in the region, the figure was 4.6 percent in 2013.

The entire article is here.

The Death Treatment

When should people with a non-terminal illness be helped to die?

By Rachel Aviv
The New Yorker
Originally published June 22, 2015

Belgium was the second country in the world, after the Netherlands, to decriminalize euthanasia; it was followed by Luxembourg, in 2009, and, this year, by Canada and Colombia. Switzerland has allowed assisted suicide since 1942. The United States Supreme Court has recognized that citizens have legitimate concerns about prolonged deaths in institutional settings, but in 1997 it ruled that death is not a constitutionally protected right, leaving questions about assisted suicide to be resolved by each state. Within months of the ruling, Oregon passed a law that allows doctors to prescribe lethal drugs for patients who have less than six months to live. In 2008, Washington adopted a similar law; Montana decriminalized assisted suicide the year after; and Vermont legalized it in 2013.

The right-to-die movement has gained momentum at a time of anxiety about the graying of the population; people who are older than sixty-five represent the fastest-growing demographic in the United States, Canada, and much of Europe. But the laws seem to be motivated less by the desires of the elderly than by the concerns of a younger generation, whose members derive comfort from the knowledge that they can control the end of their lives.

The entire article is here.

The Gray Areas Of Assisted Suicide

By April Dembosky
Kaiser Health News
Originally published May 21, 2015

Here is an excerpt:

People don’t talk about it, but it happens. Just over 3 percent of U.S. doctors said they have written a prescription for life-ending medication, according to an anonymous survey published in the New England Journal of Medicine in 1998. Almost 5 percent of doctors reported giving a patient a lethal injection.

Other studies suggest oncologists, and doctors on the West Coast, are more likely to be asked for life-ending medication, or euthanasia, in which the doctor administers the lethal dose.

“Those practices are undercover. They are covert,” says Barbara Coombs Lee, president of Compassion & Choices, an advocacy group. “To the degree that patients are part of the decision-making, it is by winks and nods.”

Coombs Lee’s organization helped tell the story of Brittany Maynard, a 29-year-old woman who moved from California to Oregon to be able to end her life legally after she was diagnosed with a brain tumor. Now the organization is backing legislation in California to make it legal for doctors to prescribe lethal medication to terminally ill patients who request it.

The entire article is here.

Stigma Around Physician-Assisted Dying Lingers

By Clyde Haberman
The New York Times
Originally posted on March 22, 2015

Here is an excerpt:

Arguments, pro and con, have not changed much over the years. Assisted dying was and is anathema to many religious leaders, notably in the Roman Catholic Church. For the American Medical Association, it remains “fundamentally incompatible with the physician’s role as healer.”

Some opponents express slippery-slope concerns: that certain patients might feel they owe it to their overburdened families to call it quits. That the poor and the uninsured, disproportionately, will have their lives cut short. That medication might be prescribed for the mentally incompetent. That doctors might move too readily to bring an end to those in the throes of depression. “We should address what would give them purpose, not give them a handful of pills,” Dr. Ezekiel Emanuel, a prominent oncologist and medical ethicist, told Retro Report.

The entire article is here.

Supreme Court strikes down Canada’s assisted suicide laws

By Laura Stone
Global News
Originally posted February 6, 2015

Canada’s high court has struck down the country’s laws against physician-assisted suicide.

That means it will no longer be against the law for a doctor to help someone who is terminally ill to end their life – but the new rules won’t kick in for a year.

And it can only be done under several conditions.

In a unanimous 9-0 decision, the Supreme Court ruled the Criminal Code laws prohibiting physician-assisted death infringes Section 7 of the Charter, which states that everyone has right to life, liberty and security of the person.

The entire article and videos are here.

Why the Right to Die Movement Needed Brittany Maynard

By Keisha Ray
Bioethics.net
Originally published November 12, 2014

Here is an excerpt:

Choice

In life many choices are not our own, but how we live our life is our choice. Maynard did not choose to have cancer invade her brain, but she did choose how to live her life after her diagnoses. After her diagnosis, Maynard remained doing the activities that had always made her life fulfilling—traveling, volunteering, and spending time with family and friends. Maynard made an informed choice to not let brain cancer kill her. She made the decision to choose how her life ends. And that’s one of the major aims of the right to die movement—that terminally ill patients ought to be able to choose how long they live with their disease and whether their disease will be the cause of their death. Disease takes away so many choices and puts people at the mercy of doctors, nurses, and most importantly it puts people at the mercy of their failing body. The right to die movements aims to take some of that power back.

The entire article is here.

Ms. Maynard was right, Assisted Suicide Should be Legal Everywhere

By Mark Bernstein
Impact Ethics
Originally posted November 10, 2014

Brittany Maynard was in the prime her life when she was diagnosed with glioblastoma multiforme, the most malignant and deadly form of brain cancer. The best available treatment consists of surgery, radiation, and chemotherapy (a pill, not intravenous) along with steroids to decrease brain swelling. Sometimes experimental treatments are undertaken. In spite of all this the vast majority of patients are dead within two years. Often patients suffer the side effects of the treatment, like hair loss, lethargy, depressed immunity causing infections, and facial bloating and weight gain from the prolonged use of steroids. Eventually they lose brain function like the ability to speak or move an arm or walk and ultimately they lose cognitive function. As a senior neurosurgeon who has dedicated his life to the care of patients with Ms. Maynard’s type of tumor and has treated thousands of such patients, I can attest to the poor quality of life many patients with glioblastoma endure.

The entire story is here.