Advertisement

The spectrum of end of life care: an argument for access to medical assistance in dying for vulnerable populations

  • Alysia C. Wright
  • Jessica C. Shaw
Scientific Contribution

Abstract

Medical assistance in dying (MAiD) was legalized by the Supreme Court of Canada in June 2016 and became a legal, viable end of life care (EOLC) option for Canadians with irremediable illness and suffering. Much attention has been paid to the balance between physicians’ willingness to provide MAiD and patients’ legal right to request medically assisted death in certain circumstances. In contrast, very little attention has been paid to the challenge of making MAiD accessible to vulnerable populations. The purpose of this paper was to examine the extant literature and resources that are available on the provision of MAiD in Canada. We found that the provision of EOLC in Canada offers insufficient access to palliative and EOLC options for Canadians and that vulnerable Canadians experience disproportional barriers to accessing these already limited resources. Consequently, we argue that palliative care, hospice care and MAiD must be considered a spectrum of EOLC that is inclusive and accessible to all Canadians. We conclude by imploring Canadian healthcare professionals, policy makers and legislators to consider MAiD as a viable EOLC option for all Canadians.

Keywords

Assisted death Medical assistance in dying Death with dignity Physician assisted suicide 

References

  1. Alberta Government. 2016a. Alberta health medical assistance in dying - what we heard. Retrieved from http://www.health.alberta.ca/documents/MedicalAssistanceInDying-WhatWeHeard-2016.pdf.
  2. Alberta Government. 2016b. Medical assistance in dying framework assures access and safeguards for Albertans. Retrieved from https://www.alberta.ca/release.cfm?xID=419044FC0B679-9E67-3233-D04EEA31DB2B3867.
  3. American Medical Association (AMA). 2016. Opinions on caring for patients at the end of life. In The AMA code of medical ethics (chap. 5). Retrieved from https://www.ama-assn.org/sites/default/files/media-browser/code-of-medical-ethics-chapter-5.pdf.
  4. Arenas, A., and Hippocrates. 2010. Hippocrates’ oath. Arion 17 (3): 73–74.Google Scholar
  5. Ball, I.M., and S. Anderson. 2017. Availability of medical assistance in dying can be therapeutic. CMAJ: Canadian Medical Association Journal 189 (9): E372.CrossRefGoogle Scholar
  6. Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). 2016. Royal Assent June 17, 2016, Forty-second Parliament, 1st session. Retrieved from http://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent.
  7. Bostwick, J.M. 2015. When suicide is not suicide: Self-induced morbidity and mortality in the general hospital. Rambam Maimonides Medical Journal 6(2), e0013.CrossRefGoogle Scholar
  8. Buckley, T. (2018). Physician assisted suicide: An end of life care option that should be available to all dying patients. Law School Student Scholarship. 943. https://scholarship.shu.edu/student_scholarship/943.
  9. Canadian Hospice Palliative Care Association (CHPCA). 2014. Fact sheet: Hospice palliative care in Canada. Retrieved from http://www.chpca.net/media/330558/Fact_Sheet_HPC_in_Canada%20Spring%202014%20Final.pdf.
  10. Chambaere, K., and J.L. Bernheim. 2015. Does legal physician-assisted dying impede development of palliative care? The Belgian and Benelux experience. Journal of Medical Ethics 41 (8): 657–660.CrossRefGoogle Scholar
  11. Chambers, S. (2017). It’s time to expand assisted-dying legislation to include advance directives for dementia. Huffington Post. Retrieved from https://www.huffingtonpost.ca/stuart-chambers/dementia-assisted-dying-legislation_b_17128476.html.
  12. Chochinov, H. M. 2007. Dignity and the essence of medicine: The A, B, C and D of dignity conserving care. British Medical Journal 335: 184–187.CrossRefGoogle Scholar
  13. Chochinov, H.M., and C. Frazee. 2016. Finding a balance: Canada’s law on medical assistance in dying. Lancet 388 (10044): 543–545.CrossRefGoogle Scholar
  14. Clarke, G., E. Fistein, A. Holland, M. Barclay, P. Theimann, and S. Barclay. 2017. Preferences for care towards the end of life when decision-making capacity may be impaired: A large-scale cross-sectional survey of public attitudes in Great Britain and the United States. PLoS ONE 12 (4): e0172104.CrossRefGoogle Scholar
  15. Claxton-Oldfield, S., and K. Miller. 2015. A study of Canadian hospice palliative care volunteers’ attitudes toward physician-assisted suicide. American Journal of Hospice and Palliative Medicine 32 (3): 305–312.CrossRefGoogle Scholar
  16. Claxton-Oldfield, S., L. Gibbon, and K. Schmidt-Chamberlain. 2011. When to say “yes” and when to say “no”: Boundary issues for hospice palliative care volunteers. The American Journal of Hospice & Palliative Care 28 (6): 429.CrossRefGoogle Scholar
  17. Cohen-Almagor, R. 2015. An argument for physician-assisted suicide and against euthanasia. Ethics, Medicine and Public Health 1 (4): 431–441.CrossRefGoogle Scholar
  18. Collins, A., and B. Leier. 2017. Can medical assistance in dying harm rural and remote palliative care in Canada? Canadian Family Physician 63 (3): 186.Google Scholar
  19. Comfort Care Choices. 2009. Whats the difference between physician-assisted suicide and euthanasia? Retrieved from http://www.comfortcarechoices.com/index.php?option=com_content&view=article&id=89:whats-the-difference-between-physician-assisted-suicide-pas-and-euthanasia&catid=37&Itemid=72.
  20. Daly, P. 2015. Palliative sedation, foregoing life-sustaining treatment, and aid-in-dying: What is the difference? Theoretical Medicine and Bioethics 36 (3): 197–213.CrossRefGoogle Scholar
  21. de Graeff, A., and M. Dean. 2007. Palliative sedation therapy in the last weeks of life: A literature review and recommendations for standards. Journal of Palliative Medicine 10 (1): 67–85.CrossRefGoogle Scholar
  22. de Lima, L., R. Woodruff, K. Pettus, J. Downing, R. Buitrago, E. Munyoro, C. Venkateswaran, S. Bhatnagar, and L. Radbruch. 2017. International association for hospice and palliative care position statement: Euthanasia and physician-assisted suicide. Journal of Palliative Medicine 20 (1): 8–14.CrossRefGoogle Scholar
  23. Gallagher, R., C. Baldwin, and D. Cargill. 2014. Palliative sedation. CMAJ: Canadian Medical Association Journal 186 (3): 212.CrossRefGoogle Scholar
  24. Huynh, L., B. Henry, and N. Dosani. 2015. Minding the gap: Access to palliative care and the homeless. BMC Palliative Care 14 (1): 62.CrossRefGoogle Scholar
  25. Institute of Medicine (IOM). 2014. Key findings and recommendations: Dying in America: Improving quality and honoring individual preferences near the end of life. Washington, DC: The National Academies Press.Google Scholar
  26. Johnson, S.M., R.J. Cramer, M.A. Conroy, and B.O. Gardner. 2014. The role of and challenges for psychologists in physician assisted suicide. Death Studies 38 (6–10): 582–588.CrossRefGoogle Scholar
  27. Kim, S.Y.H., and T. Lemmens. 2016. Should assisted dying for psychiatric disorders be legalized in Canada? CMAJ: Canadian Medical Association Journal 188 (14): E337–E339.CrossRefGoogle Scholar
  28. Kouwenhoven, P.S., N.J. Raijmakers, J.J. van Delden, J.A. Rietjens, M.H. Schermer, G.J. van Thiel, M.J. Trappenburg, S. van de Vathorst, B.J. van der Vegt, C. Vezzoni, H. Weyers, D.G. van Tol, and A. van der Heide. 2013. Opinions of health care professionals and the public after eight years of euthanasia legislation in the Netherlands: A mixed methods approach. Palliative Medicine 27 (3): 273–280.CrossRefGoogle Scholar
  29. Landry, J.T., T. Foreman, and M. Kekewich. 2015. Ethical considerations in the regulation of euthanasia and physician-assisted death in Canada. Health Policy 119 (11): 1490–1498.CrossRefGoogle Scholar
  30. Levy, T.B., S. Azar, R. Huberfeld, A.M. Siegel, and R.D. Strous. 2013. Attitudes towards euthanasia and assisted suicide: A comparison between psychiatrists and other physicians: Attitudes towards euthanasia and assisted suicide. Bioethics 27 (7): 402–408.CrossRefGoogle Scholar
  31. Lewis, B. 2017. A deliberate departure: Making physician-assisted suicide comfortable for vulnerable patients. Arkansas Law Review 70 (1): 1.Google Scholar
  32. Materstvedt, L.J., and G. Bosshard. 2009. Deep and continuous palliative sedation (terminal sedation): Clinical-ethical and philosophical aspects. Lancet Oncology, the 10 (6): 622–627.CrossRefGoogle Scholar
  33. McNeil, R., T. Kerr, B. Pauly, E. Wood, and W. Small. 2016. Advancing patient-centered care for structurally vulnerable drug-using populations: A qualitative study of the perspectives of people who use drugs regarding the potential integration of harm reduction interventions into hospitals. Addiction 111 (4): 685–694.CrossRefGoogle Scholar
  34. Mechanic, D., and J. Tanner. 2007. Vulnerable people, groups, and populations: Societal view. Health Affairs 26 (5): 1220–1230.CrossRefGoogle Scholar
  35. Meghani, S.H., and P.S. Hinds. 2015. Policy brief: The Institute of Medicine report Dying in America: Improving quality and honoring individual preferences near the end of life. Nursing Outlook 63 (1): 51–59.CrossRefGoogle Scholar
  36. National Ethics Committee, Veterans Health Administration. 2007. The ethics of palliative sedation as a therapy of last resort. American Journal of Hospice and Palliative Medicine 23 (6): 483–491.CrossRefGoogle Scholar
  37. Quill, T.E., A.L. Back, and S.D. Block. 2016. Responding to patients requesting physician-assisted death: Physician involvement at the very end of life. JAMA 315 (3): 245–246.CrossRefGoogle Scholar
  38. Rodríguez-Prat, A., C. Monforte-Royo, J. Porta-Sales, X. Escribano, and A. Balaguer. 2016. Patient perspectives of dignity, autonomy and control at the end of life: Systematic review and meta-ethnography. PLoS ONE 11 (3): E0151435.CrossRefGoogle Scholar
  39. Rys, S., R. Deschepper, F. Mortier, L. Deliens, and J. Bilsen. 2015. Bridging the gap between continuous sedation until death and physician-assisted death: A focus group study in nursing homes in Flanders, Belgium. American Journal of Hospice and Palliative Medicine 32 (4): 407–416.CrossRefGoogle Scholar
  40. Snijdewind, M.C., D.G. van Tol, B.D. Onwuteaka-Philipsen, and D.L. Willems. 2016. Developments in the practice of physician-assisted dying: Perceptions of physicians who had experience with complex cases. Journal of Medical Ethics.  https://doi.org/10.1136/medethics-2016-103405.Google Scholar
  41. Song, J., D.M. Bartels, E.R. Ratner, L. Alderton, B. Hudson, and J.S. Ahluwalia. 2007. Dying on the streets: Homeless persons’ concerns and desires about end of life care. Journal of General Internal Medicine 22 (4): 435–441.CrossRefGoogle Scholar
  42. Stienstra, D., and H.M. Chochinov. 2012. Palliative care for vulnerable populations. Palliative & Supportive Care 10 (1): 37.CrossRefGoogle Scholar
  43. Sumalinog, R., K. Harrington, N. Dosani, and S.W. Hwang. 2017. Advance care planning, palliative care, and end-of-life care interventions for homeless people: A systematic review. Palliative Medicine 31 (2): 109–119.CrossRefGoogle Scholar
  44. Tan, A., and D. Manca. 2013. Finding common ground to achieve a “good death”: Family physicians working with substitute decision-makers of dying patients. A qualitative grounded theory study. BMC Family Practice 14 (1): 1–11.CrossRefGoogle Scholar
  45. ten Have, H., and J.V.M. Welie. 2014. Palliative sedation versus euthanasia: An ethical assessment. Journal of Pain and Symptom Management 47 (1): 123.CrossRefGoogle Scholar
  46. The College of Family Physicians of Canada (CFPC). 2012. Position statement: Issues related to end of life care. Retrieved from http://www.cfpc.ca/uploadedFiles/Resources/Resource_Items/Health_Professionals/CFPC%20Position%20Statement_Palliative%20Care_ENGLISH.pdf.
  47. Tibbetts, J. 2013. Quebec’s end-of-life bill makes palliative care more transparent. CMAJ: Canadian Medical Association Journal 185 (12): 1031–1032.CrossRefGoogle Scholar
  48. Ubelacker, S. 2015. Assisted dying in Canada: On cusp of major medical shift, doctors contemplate the right they’ll have to help suffering patients end their lives. Halifax Chronicle-Herald. Retrieved from https://search-proquest-com.ezproxy.lib.ucalgary.ca/docview/1774239207?pq-origsite=summon&accountid=9838.
  49. Van Bruchem-van de Scheur, G.G., Arie J.G. Van Der Arend, C. Spreeuwenberg, H. Huijer Abu-Saad, and R.H.J. Ter Meulen. 2007. Euthanasia and physician-assisted suicide in the Dutch homecare sector: The role of the district nurse. Journal of Advanced Nursing 58 (1): 44–52.CrossRefGoogle Scholar
  50. Vedel, I., V. Ghadi, L. Lapointe, C. Routelous, P. Aegerter, and F. Guirimand. 2014. Patients’, family caregivers’, and professionals’ perspectives on quality of palliative care: A qualitative study. Palliative Medicine 28 (9): 1128–1138.CrossRefGoogle Scholar
  51. Watt, S., M. Li, M. Gardam, M. Escaf, G. Rodin, G. OELeary, and A. Heesters. 2017. Medical assistance in dying-implementing a hospital-based program in Canada. The New England Journal of Medicine 376 (21): 2082.CrossRefGoogle Scholar
  52. World Medical Association (WMA). 2015. End-of-life-issues. In The World Medical Association’s medical ethics manual. 3rd ed., 59–60 Ferney-Voltaire: World Medical Association (WMA).Google Scholar
  53. Yuill, K. 2015. The unfreedom of assisted suicide: How the right to die undermines autonomy. Ethics, Medicine and Public Health 1 (4): 494–502.CrossRefGoogle Scholar
  54. Zenz, J., M. Tryba, and M. Zenz. 2015. Palliative care professionals’ willingness to perform euthanasia or physician assisted suicide. BMC Palliative Care 14 (1): 60.CrossRefGoogle Scholar

Copyright information

© Springer Nature B.V. 2018

Authors and Affiliations

  1. 1.Faculty of Social WorkUniversity of CalgaryCalgaryCanada

Personalised recommendations