Column: Provinces vary on access to assisted dying

by Allan Woods

Quebec has had most requests, while much of Canada hasn’t reacted yet

Some provinces have neglected or been slow to adopt a recommended measure to ensure patients wanting an assisted death can get it and that doctors who offer it are sheltered from professional stigma and physical threats, a review by the Toronto Star has found.

Medical experts have urged Canadian health authorities to create publicly funded coordination or referral agencies that would make sure patients who want to end their lives can find doctors willing to perform the procedure.

Yet one month after the controversial law was adopted on June 17, only a few jurisdictions – Alberta, Ontario, Manitoba, New Brunswick and Northwest Territories – have such a centralized service in place.

Some, including Saskatchewan and Prince Edward Island, are compiling lists of doctors who would be willing to administer a deadly drug cocktail on request from a terminally ill patient who meets the requirements.

In Quebec, where doctor-assisted death has been legal since December, it is the responsibility of doctors who refuse to perform the procedure to refer their patient to another physician. The Quebec and Nova Scotia health ministries confirmed they have no central referral service.

Health Canada would also like to see all provinces set up care-coordination services, although there will be no requirement in coming federal regulations to require that, a spokesperson said. Without it, health officials fear terminally ill patients and their families will have to shop around for a physician willing to fulfill their wishes.

Canadian Medical Association surveys suggest it is a real concern. Sixty-one per cent of doctors in one survey identified as conscientious objectors to assisted death. Two-thirds said they’d be reluctant to refer patients to a willing colleague, said president Dr. Cindy Forbes.

“The issue of conscientious objection is huge and it’s related to the issue … of how physicians feel about this,” she said in an interview. “Some of them are obviously quite uncomfortable about referring as well.”

Coordinating bodies can also protect physicians willing to carry out the procedure but reluctant to advertise the fact or to risk being identified as a provider of euthanasia.

That sentiment comes as no surprise to Dr. James Silvius, the medical director of Alberta’s Medical Aid in Dying program. “In the early days of this, we got hate mail. I’ve been publicly identified early on as doing this work. We have an email address, and I’ve been told I’m a murderer and other things,” he said.

Alberta was among the first to set up a central service that maintains lists of doctors and pharmacists willing to take part. Only the medical director in each of Alberta’s five health zones has access to the list of doctors in their jurisdiction. Not even Silvius knows the names.

“We could become targets, and we don’t want that to happen,” he said, addng that the list of willing pharmacists is also “very tightly held.”

The emotional debate on assisted dying has focused on medical ethics and protections for physicians opposed to it. There has been less attention paid to doctors who are willing to end a patient’s life but fear protests, harassment or even physical violence.

“We are aware that physicians are concerned about the potential of unwanted interference,” said Dr. Douglas Bell, associate executive director with the Ottawa-based Canadian Medical Protective Association.

He noted that in cases before the federal law was passed in which terminally ill patients sought a court order to get an assisted death, physicians asked the judges to keep their identities confidential.

“That probably dates back to the abortion struggles,” Dr. Bell said.

In Prince Edward Island, authorities are surveying physicians on whether they are willing to discuss assisted dying with patients, willing to offer the service only to their own patients, or would provide it to any patient on request, the province’s manager of physician services, Lauren Kelly, said in a statement.

“We do recognize that not everyone is comfortable with medical assistance in dying and it is for that reason that we will not be disclosing which primary-care providers are willing to be part of this new service,” she said.

On the other side of the debate, medical professionals who object to providing assisted dying also feel they are being singled out.

The McGill University Health Centre announced it was changing some of its policies on assisted dying after criticism that those policies discouraged patients from getting the procedure. The hospital initially refused to carry out the procedure in the palliative care ward, where end-of-life care is the specialty. It also had a policy that patients had to have been seen at the institution in the 18 months prior to their request.

Critics included Quebec Health Minister Gaetan Barrette, who called the policies a “childish” reaction to the opposition views of the hospital’s palliative care staff. Others suggested that they explained why only two patients had received a hastened death at the hospital in six months – a figure among the lowest in Quebec.

The head of the hospital’s palliative care unit, Dr. Manuel Borod, recently challenged that view, saying the figures were so low because of the high quality of palliative care, which minimized patient suffering.

“The real question you should be asking is: Why are so many cases of medical aid in dying taking place elsewhere and so few at the MUHC?” he told journalists.

Dr. Eugene Bereza, director of the McGill hospital’s Centre for Applied Ethics, said the debate in Quebec about how many procedures are being completed may have more to do with differences in interpretation.

“My sense is not so much a polarization in terms of stigma where people are saying, ‘You’re a euthanizer,’ and ‘You’re a fundamentalist,'” he said, emphasizing that it was still too early to draw conclusions. “I think there is still some basic confusion about some elements in the law and regulations. You’d think they’d be perfectly clear, but they’re not.”

Quebec’s oversight body that reviews each assisted-dying case has even issued a letter to physicians indicating that they have performed the procedure on patients not in a terminal phase as set out in provincial law, Radio-Canada reported.

“Some people think aid-in-dying can be 12 months or more (before death is expected) whereas others think it means weeks – maybe a month or two. That can make a big difference,” Bereza said.

Some assisted-dying opponents feel their principles have made them targets, said Dr. Cathy Ferrier, a physician in the McGill hospital’s geriatrics division and president of Physicians’ Alliance Against Euthanasia.

Quebec’s palliative-care centres unanimously decided last fall to refuse to provide assisted dying because of their philosophical objections. They are now fearful of losing their public funding, Dr. Ferrier said.

“I know of people who were trying to start a new palliative-care centre that they’d been working on for several years and were told this year that they would not get public funding,” she said. “Is that because they don’t intend to euthanize patients? I don’t know, but it could be.”

Doctor-assisted death cases in Canada

Alberta: 9 completed procedures

25 requests currently being processed

Ontario: 18 completed procedures (6 since adoption of the federal law, 12 for which patients obtained a
court order)

British Columbia: The B.C. health ministry refused to reveal how many procedures have been carried out

Saskatchewan: 1 completed procedure (fewer than five requests to date)

Fewer than five requests have been received from patients

Manitoba: 5 completed procedures 35 requests, including six that are currently being considered

Quebec: 166 completed procedures up to the end of June 2016, according to Radio-Canada 254 requests, including 87 whose requests were either turned down or who changed their minds

*Quebecís doctor-assisted dying law has been in effect since Dec. 2015

Prince Edward Island: 0 procedures completed

Nova Scotia: The Nova Scotia health ministry refused to say how many procedures have been completed

New Brunswick: 0 procedures completed

Newfoundland: 0 procedures completed

1 request (patient died of natural causes before receiving procedure)

Nunavut: N/A

Northwest Territories: 0 procedures completed

0 requests

Yukon: N/A

Copyright 2016 – Torstar Syndication Services

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