Assisted Dying.

[Kirkhill]

I approach with trepidation.  I want to keep politics out of this as much as possible.  If it gets too heated I will ask the moderators to shut this thing down quickly.

I am an orphan.  Both of my parents died in their 50s of cancer.  My father elected treatment. My mother rejected treatment. Both died.  Neither died pleasantly.  My mother had a marginally better end - self-medicating with morphine in a public hospital.

I am of two minds with respect to assisted dying as I suspect most people are.  Some days I understand the need and am accepting.  Some days I reject the need.  Some days I accept the need but reject the accommodation because it can be an overly attractive solution. 

I also have real problems with anybody acting for another person in this matter - proclaiming an ability to understand that person's wishes better than the person themselves is able to voice.  That person is the unfortunate one who cannot be granted relief on exactly the same grounds that the death penalty was abolished. The risk of an "innocent" or in this case "unwilling" person dying is too great.  The guilty must go free.  The sufferer can't be granted release - unless they specifically ask for it at the time.

That is background.

I want to move on to the mechanics of assisting the dying.  The expectation is that medical practitioners will be providing the service mandated by the state, or in fact by the courts, simply because they are by and large employees of the state.  But many practitioners are opposed on moral grounds and all practitioners have taken oaths "to do no harm".  For whatever an oath is worth these days insofar as courts seem to permit people to cross their fingers and change their minds.

To manage the problem of competing oaths I suggest the following:

The return of the Public Executioner.

The Executioner is the person hired to execute the wishes of the state.  Much like a soldier.

Soldiers should not be executioners in this sense.  Equally doctors should not be executioners.

If the state and the courts have determined that society must provide assistance in dying then I suggest it is up to the state and the courts to employ such people as are necessary to execute the wishes of the state and the courts and provide such assistance as they deem appropriate when a citizen requests his or her demise.

Of course, given the current wide interpretation of when assistance is appropriate, it may be that the Public Executioner finds themselves confronted by individuals for whom the prospect of life, 25 years, 15 years, 5 years behind bars is just too hard to bear and are requesting assistance.

 

[ModlrMike]

As someone who may at sometime be asked to render such assistance, I admit that I'm still unclear on the idea.

The thing that most people struggle with is coming to terms with what it means to them. For example, when I admit folks to hospital, I need to have an understanding of their wishes vis-a-vis resuscitation. You would be surprised at the number of families that want their 96 year old, demented and vegetative relative to undergo a full resuscitation. They're clearly making the choice based on their own perspective, and not on their relative's wishes.

The assisted dying discussion is similar. Everyone has to understand and come to terms with the outcome. It's going to be hard on surviving family members, but by the same token they should not guilt the person suffering into prolonging their situation. To be fair though, the person seeking assistance has to understand the knock on effects of their decision.

Personally, I think the current legislation is poor document.

As to the suggestion of an Executioner... That's a poor term in that execution is something imposed on you, not something you choose for yourself. Semantics perhaps, but an important distinction in this discussion.

 

[Kirkhill]

As someone who may at sometime be asked to render such assistance, I admit that I'm still unclear on the idea.

The thing that most people struggle with is coming to terms with what it means to them. For example, when I admit folks to hospital, I need to have an understanding of their wishes vis-a-vis resuscitation. You would be surprised at the number of families that want their 96 year old, demented and vegetative relative to undergo a full resuscitation. They're clearly making the choice based on their own perspective, and not on their relative's wishes.

The assisted dying discussion is similar. Everyone has to understand and come to terms with the outcome. It's going to be hard on surviving family members, but by the same token they should not guilt the person suffering into prolonging their situation. To be fair though, the person seeking assistance has to understand the knock on effects of their decision.

Personally, I think the current legislation is poor document.

As to the suggestion of an Executioner... That's a poor term in that execution is something imposed on you, not something you choose for yourself. Semantics perhaps, but an important distinction in this discussion.

Just want to clarify the semantics of the word "Executioner":  as I noted the role of the Executioner was to execute the will of the state, which arrogated to itself to power to kill.  The state now wishes to "lend/donate" that power to willing citizens.  I suggest that they "lend/donate" the services of the Executioner as well.

I particularly like the connotations and associations of the word.  I think it would serve as a reminder of the gravity of the decision and confirmation that the procedure is not a medical one.

 

[mariomike]

Saw this in the news,

May 11, 2016

Suffering from PTSD resulting from sexual abuse? Dutch doctors will euthanize you.
https://www.lifesitenews.com/news/dutch-doctors-kill-sex-abuse-victim-because-of-incurable-mental-suffering
The Dutch decriminalization has been expanded since 2002 to include the mentally ill and those suffering from dementia. Children as young as 12 years old can request euthanasia with the support of their parents, and the Dutch Pediatric Association is publicly advocating the elimination of any minimum age to request it. More than 5,000 people are killed by their physicians or commit suicide with their help every year, according to official statistics.

See also,

Mercy Killing? Euthanasia?
http://army.ca/forums/threads/91849.50.html
3 pages ( Locked ).

I want to move on to the mechanics of assisting the dying. 

 

[jollyjacktar]

I am disappointed that once again the state is acting like a nanny state and getting their face into what I feel is my business and mine alone.  It is my life and I would like to have a mechanism it end it in a dignified manner at a place, method and time of my choosing should I have a need and desire for this path.  Now, I feel that I will have to take a walk into the woods in winter or something if  I must. For once the Senate, much to my shock, was actually leaning more towards how I feel on the subject, unlike the "Sunshine State" that inhabits the Hill.  Another reason to curl my lip at them.

 

[mariomike]

Now, I feel that I will have to take a walk into the woods in winter or something if  I must.

Just don't go in too deep. Think of the guys/gals who have to carry you out. 

 

[jollyjacktar]

Exactly, and one thing among others that would give me pause.

 

[mariomike]

Exactly, and one thing among others that would give me pause.

I would be too afraid of botching the job to try. 

 

[The Bread Guy]

First off, thanks, all, for sharing on a topic that reaches pretty deeply inside of us, whether we realize it or not.

... The expectation is that medical practitioners will be providing the service mandated by the state, or in fact by the courts, simply because they are by and large employees of the state.  But many practitioners are opposed on moral grounds and all practitioners have taken oaths "to do no harm". For whatever an oath is worth these days insofar as courts seem to permit people to cross their fingers and change their minds ...

I stand to be corrected by people in the medical field on these boards, but I'll say it:  there are patients in the system getting big doses of morphine "in order to make them comfortable" as part of very-end-of-life care.  This is already happening - I've seen this twice.  In the situations I saw, I had no problem with how it was done.  Can abuse happen?  Yup.  Does that mean we shouldn't come up with rules?  I'd think the opposite.  Is the current law, as is, enough?  I don't think so.

On the oath re:  "do no harm", again, I'd love to hear more from medical practitioners, but the original oath talked about "I will not give to a woman a pessary to cause abortion," and we know such procedures happen, too.  One source that doesn't look crazy says the "original" oath has undergone a certain amount of development.  And when it comes to "doing no harm", is it more harmful to let someone suffer for a longer time, or to stop the suffering sooner?  Each case will have it's own answer, but if the latter is not an option, we'll be stuck with the former until pain management/control gets better.

I am disappointed that once again the state is acting like a nanny state and getting their face into what I feel is my business and mine alone.  It is my life and I would like to have a mechanism it end it in a dignified manner at a place, method and time of my choosing should I have a need and desire for this path ...

Problem is that before this law, if you wanted to end it your way, anyone helping you could go to jail.  That said, I agree the current law has a big short-coming - not being able to include such wishes in an advanced directive in the event you become mentally incompetent down the road - that would addresses this bit:

... I also have real problems with anybody acting for another person in this matter - proclaiming an ability to understand that person's wishes better than the person themselves is able to voice ...

... doctors should not be executioners ...

On a practical level, I'd prefer someone who knows how it's done than a technician.
Finally ...

... Now, I feel that I will have to take a walk into the woods in winter or something if I must ...

... I've heard a number of people say that, and I believe in "I'm the boss of me" as well, but also keep in mind what this option does to those you leave behind -- that's why we need better.

 

[Kirkhill]

First off, thanks, all, for sharing on a topic that reaches pretty deeply inside of us, whether we realize it or not.
I stand to be corrected by people in the medical field on these boards, but I'll say it:  there are patients in the system getting big doses of morphine "in order to make them comfortable" as part of very-end-of-life care.  This is already happening - I've seen this twice.  In the situations I saw, I had no problem with how it was done.  Can abuse happen?  Yup.  Does that mean we shouldn't come up with rules?  I'd think the opposite.  Is the current law, as is, enough?  I don't think so.

See my original post re morphine. 

With respect to the making of laws I am very much of the opinion that this is a situation where Common Law triumphs over Civil Code.  Customary practice and precedence is a much more flexible tool than chiseling codes in stone after interminable arguments by blind men over what constitutes an elephant.

On the oath re:  "do no harm", again, I'd love to hear more from medical practitioners, but the original oath talked about "I will not give to a woman a pessary to cause abortion," and we know such procedures happen, too.  One source that doesn't look crazy says the "original" oath has undergone a certain amount of development.

Regardless of the original intent, or wording, the issue, surely, is the understanding of those that utter the current words.  And the vast majority of those, I believe, would not find the taking of life to be compatible with their oath.

And when it comes to "doing no harm", is it more harmful to let someone suffer for a longer time, or to stop the suffering sooner?  Each case will have it's own answer, but if the latter is not an option, we'll be stuck with the former until pain management/control gets better.

Again, this is why I would prefer a Common Law remedy rather than a Code Civil remedy.

Problem is that before this law, if you wanted to end it your way, anyone helping you could go to jail.  That said, I agree the current law has a big short-coming - not being able to include such wishes in an advanced directive in the event you become mentally incompetent down the road - that would addresses this bit:

I think that each case is sufficiently different, and sufficiently grievous, that each decision needs to be thoroughly reviewed after the fact with dire consequences for the practitioner in the case of error.

On a practical level, I'd prefer someone who knows how it's done than a technician.

I don't find it hard to contemplate a competent technician specializing in painless death.  Even the old hangmen had notable skills to ensure the clean snap of the neck.

Finally ...... I've heard a number of people say that, and I believe in "I'm the boss of me" as well, but also keep in mind what this option does to those you leave behind -- that's why we need better.

And that is the biggest issue of all - and why nobody should be given a free pass from the courts on making these decisions.  Every decision should be the subject of judicial review.

 

[The Bread Guy]

With respect to the making of laws I am very much of the opinion that this is a situation where Common Law triumphs over Civil Code.  Customary practice and precedence is a much more flexible tool than chiseling codes in stone after interminable arguments by blind men over what constitutes an elephant.

Then you have more faith in how people apply common law (over something a bit more codified)  ;D

Regardless of the original intent, or wording, the issue, surely, is the understanding of those that utter the current words.  And the vast majority of those, I believe, would not find the taking of life to be compatible with their oath.

Some?  Yes.  Most?  I'm not convinced.  Some surveys say most say no, some surveys say most say OK, but in certain circumstances.  Again, I'd love to hear from any practitioners out there on this one because I'm just guessing based on doctors & other health professionals I've spoken to.

I think that each case is sufficiently different, and sufficiently grievous, that each decision needs to be thoroughly reviewed after the fact with dire consequences for the practitioner in the case of error ... And that is the biggest issue of all - and why nobody should be given a free pass from the courts on making these decisions.  Every decision should be the subject of judicial review.

More than fair, which can also be built into a system where the patient can express a choice.

I don't find it hard to contemplate a competent technician specializing in painless death.  Even the old hangmen had notable skills to ensure the clean snap of the neck.

Then that might be my own squeamishness, then.  Maybe the term "executioner" as a term?  Mostly because this individual would be carrying out the wishes of the patient, not the state.

 

[Kirkhill]

I always favour the crowd over the expert.  And as someone that has been paid to be an expert I say that advisedly. 

On the some, most, many question - it doesn't matter if it is one that is being forced to compromise their principles.

And on the "executioner" front:  I want you to be squeamish.

I believe the sequence of events should go something like this:

Doctor to Patient - I can't do any more for you.

Patient to Doctor - I want to die

Doctor to Patient - Here is the phone number of the Public Executioner.

 

[medicineman]

Was thinking hard about entering this or not, but like Mike, I too may be faced with this.  Oddly enough, I am actually for it.  "Primum non nocere" means not just don't frig up and do what is right, it also means don't make your patient suffer.  I've watched more than my share of people go through the dying process - both over the long haul and also very short ones - and both are difficult for all around, be that family, friends, care givers.  I've seen some family members that try to drag things out, sometimes because they're trying to control the uncontrollable, others because there are financial or plan old vengeful back stories, and others because of religious reasons.  Whatever the case, if the person is competent to make the decision ahead of time, there is going to be a known and protracted period of suffering ahead of their demise resulting directly from this illness or injury, they should be afforded the dignity to do ask someone to end things for them at a time of their choosing.

One of the little problems about some of our laws is that there are some religious backgrounds around suicide, especially with the Roman Catholic and other Christian churches that our original lawmakers were active members of.  This kind of clouds the objectivity of people when it comes to death.  There are also many folks that walk this earth that figure we can and should prolong people's existence well beyond their best before dates (which, incidentally, we all have).  Fact is that today, people have a very unrealistic expectations of what constitutes "a life" and what doesn't.  If I ever got to the point where I were to end up like some of my PCH patients from my previous job, I'd literally arrange to fall on my katana at home, perhaps more than once.  The reason is this - I am pretty good at keeping people alive that should have died several years ago by tweeking this biochemical or physical parameter in one direction or the other; however, keeping that physical person living a GORK (God Only Really Knows) 'ed out existence, completely unaware of who, what, where and when they are and being completely dependent on others more so than a baby, well that to me isn't a life.  I vividly recall a person that was past 100 years old, with no living friends, who'd wake up each day and look at us and, realising they was still on Earth, would drop their head and ask "Why am I still here??!!".  Not an easy thing to take...

I well remember reading a bio of Dr Sir William Osler, one of the great medical minds of the 19th and early 20th Centuries (and a Canadian...and someone I sometimes quote at work) where it was clearly written in a patient chart where he'd done a housecall in Montreal during the last big smallpox epidemic and having not much to offer, gave this patient a fairly decent dose of morphine...which not only eased their suffering, but also hastened their demise later that evening.  Using the law of the time (and really not so distant past), by the letter, he should have been strung up from the gallows for murder...however, ethically, I (and many others I'm sure) feel this was merely doing good by his patient, which is what this MAID law is about. 

This law is about empowering people and their caregivers to do what they feel is necessary for them, in a dignified and LEGAL manner.

:2c:

MM

 

[mariomike]

You would be surprised at the number of families that want their 96 year old, demented and vegetative relative to undergo a full resuscitation.

Or, sometimes they don't  want paramedics to resuscitate. The family hands you a DNR order signed by the doctor.

But, in Ontario, when called to respond to a scene where a person has lost vital signs, and in the absence of a Do Not Resuscitate Confirmation Form (DNRCF), even if a DNR Order is presented to attending paramedics, under regulations of the MOHTLC, paramedics must begin resuscitative measures.

 

[The Bread Guy]

Thanks, medicineman, for sharing an "inside the profession" view.

But, in Ontario, when called to respond to a scene where a person has lost vital signs, and in the absence of a Do Not Resuscitate Confirmation Form (DNRCF), even if a DNR Order is presented to attending paramedics, under regulations of the MOHTLC, paramedics must begin resuscitative measures.

And THAT is an important point for people in Ontario to know - thanks for sharing.

 

[mariomike]

And THAT is an important point for people in Ontario to know - thanks for sharing.

The DNR-CF is the only  order Ontario paramedics can accept as a DNR directive.

Each one has a unique 7-digit serial number.

 

[dapaterson]

Which is why some palliative care doctors advise against calling paramedics. 


Medicineman: Anecdotally I have heard of modern-day doctors who have similar approaches to pain management with morphine.  Perhaps with appropriate legislation they can do it "on the books" instead of doing it with a wink and a nudge.

 

[The Bread Guy]

The DNR-CF is the only  order Ontario paramedics can accept as a DNR directive.

Each one has a unique 7-digit serial number.

Where does one get one of these forms?  I know people with DNRs and advance directives who live @ home.

 

[mariomike]

Where does one get one of these forms?  I know people with DNRs and advance directives who live @ home.

I suspect some may not have heard of the DNR-CF, or believe it is necessary.

Perhaps they could be shown this from THE ONTARIO COLLEGE OF FAMILY PHYSICIANS:
http://ocfp.on.ca/docs/communications/january-21-2008.pdf?sfvrsn=4

Do Not Resuscitate Confirmation Form
Dear Colleague,
Recently, paramedics and firefighters have been authorized to honor the “Do Not Resuscitate” (DNR) orders of a patient. I would like to make certain that you are aware of the new form, The Do Not Resuscitate (DNR) Confirmation Form which will be the only form accepted in Ontario for this purpose as of February 1, 2008.
Like many of you, I care for patients at the end of life who wish to die in their own homes. A DNR order is appropriately obtained, documented and well known by all healthcare providers, caregivers and family involved. On occasion, for various reasons, 911 is called and paramedics and firefighters are required to attend the patient’s home to offer emergency assistance and/or transport the patient to hospital for further care. Currently paramedics are legally obliged under the Ambulance Act’s Basic Life Support Patient Care Standards, Version 2, to initiate life support measures (chest compression, defibrillation, artificial ventilation, insertion of an airway, endotracheal intubation, transcutaneous pacing or advanced resuscitation medications) to all patients irrespective of their personal directives or any current institutional DNR order. As you can well imagine, inappropriate resuscitative procedures often ensure contrary to the patient’s, family’s and physician’s wishes and orders. This often leads to significant detrimental consequences for the patient and family and is inappropriate use of limited human and financial resources.
To address this issue, and to ensure that a standardized process that allows paramedics and firefighters to honor the DNR wishes of patients, a DNR Task Force was convened in September 2003. Its efforts have resulted in the new The Do Not Resuscitate Confirmation Form, which will become the new standard of care in Ontario as of February 1, 2008. When this form has been completed by a physician or nurse (RPN, RN, RN (EC), paramedics and firefighters will now be authorized to withhold life support measures (as defined above). In addition, they will now be authorized to provide comfort (palliative) care as appropriate (oropharyngeal suctioning, O2, nitroglycerin, salbutamol, glucagon, epinephrine, opiods, ASA or benziodiazepines).

To access the enclosed form DNR Confirmation Form, go to the Government of Ontario website:
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/AttachDocsPublish/014-4519-45~`/$File/4519-45.pdf
It can be ordered by going:
http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?OpenForm&ACT=RDR&TAB=PROFILE&ENV=WWE&NO=014-4519-45
More specific information and details regarding the form and its use can be obtained in the following Ontario Medical Review article:
Verbeek PR, Sherwood C. End-of-life care in the home: How a new procedure for Ontario paramedics and firefighters may affect your patients and your practice. Ontario Medical Review 2007 November; Vol 74 (10):39-42. Please go to: https://www.oma.org/pcomm/OMR/nov/07maintoc.htm
Family physicians will play a pivotal role in the successful implementation of this new standard. It is up to those of us who provide care at home to patients at the end of life who must now make concerted efforts to ensure that this new process will honor our patients’ wishes and prevent the untoward consequences which occur too often despite our best intentions.
Sandy Buchman MD CCFP FCFP
Past President
The Ontario College of Family Physicians

 

[medicineman]

Medicineman: Anecdotally I have heard of modern-day doctors who have similar approaches to pain management with morphine.  Perhaps with appropriate legislation they can do it "on the books" instead of doing it with a wink and a nudge.

One would hope...

In Manitoba, we have a form called "Notice of Anticipated Death at Home" we send to the Chief Medical Examiner's office once someone is into their final days/weeks, so that all that needs to occur is someone to fill out the Certificate of Death with time and date and call the funeral home to remove the body.  The thing that used to annoy the crap out of me was the fact we couldn't do that for PCH residents, even though the PCH was their home - they always became notifiable deaths, so there was a decent amount of paperwork to be done, I had to talk to the Medical Investigator at the ME's office, etc.

MM