5 minute read
MAID: Reconciling the law, ethics, and clinical care
By Dr. Lilian Thorpe
Dr. Lilian Thorpe is a geriatric psychiatrist who completed her medical degree at the University of Toronto in 1982. After moving to Saskatoon with her husband, she did her residency training in psychiatry and later a PhD in community health and epidemiology. Dr. Thorpe has been clinically involved with medical assistance in dying since before Bill C-14 came into effect in June 2016, and has been involved in a large number of related teaching and academic activities since that time.
As a young intern at St. Paul’s Hospital in Saskatoon, I had a very difficult experience with death. A 16-yearold boy was dying of cancer, and as the intern looking after him I spent all my spare time with him and his family. When he died during a long night shift, I became very distressed with the unfairness of such a young person having to die before living the rest of what could have been a wonderful life.
I was able to be a support for him and his family but I myself felt traumatized. A wonderful nun, whose name I have long forgotten, sat with me after the night shift and talked about the meaning of life, death, and the bad things that sometimes happen to good people. The Grey Nuns were still very much a presence at the hospital at that time and without her I am not sure I could have gotten through the rest of even the next day or weeks.
Throughout that internship year I spent much time thinking about my personal and professional priorities. After working with Dr. David Keegan during an elective, I decided to make a career change from pediatrics to psychiatry and over the years this evolved into a focus on geriatric psychiatry.
Assessment of capacity has been a large part of my work in the field, so when Bill C-14 passed, I was approached to be part of the Saskatoon Health Region ethics subcommittee developing the medical assistance in dying (MAID) policy. This began in advance of the anticipated release of legislation permitting physicians and nurse practitioners to assist in the dying process, and we had a very productive multidisciplinary group spearheaded by our chair, Dr. Susan Hayton, to work on this.
The committee eventually developed a careful, holistic approach, blending legal requirements, ethics, and clinical practice; it still informs most of my approach to medical assistance in dying
I became one of the assessors and on rare occasions also a provider. I think I assessed every single person in our health region who had an assisted death up until the end of December 2019! We travelled widely throughout Saskatchewan at first, since few health-care providers were willing to get involved with this very new process. As the only psychiatrist involved I have also been available to provide a second opinion in difficult situations, particularly when mental capacity was unclear.
I have felt very privileged to be part of the lives of many patients and their families during their journey at the end of life. People going through this are often very open to sharing their experiences, sometimes feeling a great need to talk through unresolved issues dating back to their childhoods. Sometimes difficult stories come up, such as difficult wartime experiences and exposure to very traumatic deaths.
Families of patients who have chosen to go through an assisted death often contact me later, to provide an update on how their lives are going. Although death is always sad, family members almost always express great gratitude for our involvement, whether or not the person ends up choosing an assisted death. Many people are relieved to know they have an option, and then proceed with the normal dying process, knowing that with all the paperwork completed their suffering could be ended if it becomes totally unbearable.
Many challenges lie ahead for all of us in Canada with the broadening of eligibility criteria to remove reasonably foreseeable death, which will likely occur within the next few months. Eventually patients with solely mental health conditions and mature minors will also become eligible, and people will be able to indicate in advance care directives that they want to have an assisted death. All of these changes will need considerable dialogue and collaboration in developing appropriate processes to balance autonomy and vulnerability.
I feel strongly that our approach to medical assistance in dying needs to be a holistic one. Initial assessments should be very careful and comprehensive, starting with exploration of the usual geriatric principles of deprescribing, discontinuation of invasive interventions which are no longer contributing meaningfully to the quality of life, consideration of symptom management including with palliative care, and lastly exploring medical assistance in dying. If we provide good, holistic care throughout a person’s lifespan I hope that most will be able to die naturally without an assisted death. However, I think there will always be people whose dying is highly traumatic and no interventions, not even perfect inpatient palliative care, can take away the immense personal distress in the dying process. This is quite clear from our regional data audits, which show us that most people who have had an assisted death have also already had palliative care.
Finally, we must continue to work on strong interactive training for assessors in particular, who increasingly will have to deal with complex patients as the public becomes more aware of MAID as an option. Often we don’t know what we don’t know. All assessors should be provided opportunities to learn about the particular vulnerabilities of patients who might request an assisted death, some of whom are going through an exacerbation (which might improve eventually) of a previously stable condition, or who are not yet adapted to a new life circumstance such as a spinal cord injury. In the end, using good clinical processes and remembering that a medical decision is more than following legal recommendations, is what we all need to do in meeting the challenges of this very new part of medicine. ◆
