The BC Supreme Court decided to eliminate the ban on Physician Assisted Suicide last month. In the aftermath it appears that there is considerable confusion on the definition of Physician Assisted Suicide as well as related terms. I felt it was important for me to provide clarity on some of these issues.
It is essential that we help students and health care staff to understand the following terms:
- Allow natural death
- Do not resuscitate
- Palliative sedation therapy
- Assisted suicide
1. Simply put, “ALLOW NATURAL DEATH,” indicates that the person does not want artificial means to keep them alive. What does this look like?
When they are no longer able to eat solids, do not put in a feeding tube.
If they are no longer able to swallow fluids try thicker fluids.
If they are not able to swallow thickened fluids, provide mouth care.
If they can not breathe independently do not put them on a respirator.
When their heart stops beating they do not attempt to resuscitate them.
It does not mean withholding comfort measures. Ideally the person’s Advance Care Plan will inform their substitute decision makers if they want treatments such as antibiotics for an infection.
2. Do NOT resuscitate – should more accurately be “Do NOT ATTEMPT resuscitation“. Far too often I hear people ask “If you die do you want to be resuscitated?” We can not in truth offer this! We can only offer to ATTEMPT resuscitation.
And of course, the other piece of information that we should provide is the correct information on how often CPR is effective for someone with their condition, and what the negatives effects of performing CPR on this person would be. For example, this procedure can be invasive, result in broken bones, and can interfere with the family being able to share a more gentle style of being with and caring for a person in the last moments and being with them following death.
3. Sedation or Consequential Sedation… (also known as drowsiness) is a common side effect of medications for symptom management. Sometimes the person receiving the medication, (example – Morphine), may be drowsy for a few days after starting the medication or following the increase in dose. This is a normal side effect.
If the person is not dying, then the side effect usually wears off within about 3 days.
If the person is dying, then they will be sleeping more because of the dying process, not because of the medication. This is very important for families and staff to understand. Far too often family think their loved one is dying or has died because of medication. They need good information sharing to understand that the normal dying process includes increase in sleeping, and to discuss the effects of medication. This is different than Palliative Sedation Therapy.
4. Palliative Sedation Therapy is an emerging therapy used in the last days when death is imminent and when symptoms are not able to be controled by other means. Medications are provided to manage the symptoms and the person is deeply sedated through to time of death. Guidelines for Palliative Sedation Therapy are being developed. This is not the same as sedation that results when a person’s symptoms are being managed, and person is drowsy as a side effect (as above).
5. Physician Assisted Suicide is when a person requests assistance in dying. They may do this because they have a terminal illness and are not sure that they will be able to carry out the suicide without assistance. This is legal in a few states. If this become legalized in Canada, guidelines will outline the procedures to follow.
6. Euthanasia is when people are terminated without their request. Over the years there has been concern expressed about the “slippery slope”, concern that people who do not ask for assisted suicide will be euthanized. Groups that are particularly concerned about this are those who protect the rights of peple with disabilities, the elderly, and other vulnerable populations.
7. Finally, there are people who wonder if Hospice Palliatiave Care is a form of Physician Assisted Suicide.
Hospice Palliative Case is all about improving the quality of living: It is not about hastening death.
In Physician Assisted Suicide, medication is given to terminate a life, to achieve death: In Hospice Palliative Care, medication is given to provide comfort, to achieve comfort. There is a difference. On a practice level there is a difference.
The proponents of Physician Assisted Suicide and the philosophy and goals of Hospice Palliative Care share some similarities. Both desire to provide, or help provide a death with dignity. It is inaccurate for the media to portray that death without Physician Assisted Suicide is not dignified.
This quote from the Canadian Hospice Palliative Care Association is appropriate:
“In the hospice palliative care experience, the process of dying has meaning and purport for the person as well as his or her loved ones. As a field of practice, we have the responsibility to ensure that all those involved in providing hospices palliative care have the knowledge (including an understanding of the alternatives to physician-assisted suicide), attitude and skills to help people at end-of-life manage both physical and emotional suffering, and to support family members. We also have a responsibility to ensure that patients seeking physician-assisted suicide are aware of other options.”
For further information, discussion paper of issues related to Physician Assisted Dying, and defintions of terms
What terms do you feel need to be defined or clarified?
This is probably the best use of a tattoo that I have ever seen!
I agree,… I may have to book an appointment with the local tattoo artist!
Thanks for writing this article. I appreciate the simple explanations, they will be helpful in educating my students about these terms.
You are so welcome!
People in hospice/palliative care understand these terms/concepts. Patients and families who are fortunate enough to have access to hospice/palliative care likely would never consider physician assisted suicide because they would be comfortable and supported to make the best of the time they had left. Where I see the difficulty is for the patients who are cared for by physicians who believe cure is always an option and must be persued at all costs. This usually results in a very undignified and painful death where quantity of life is foremost not quality. In my 47 years of nursing practice, I see this over and over in acute care and patients and families can only make decisions based on the information they are given. Much more emphasis needs to be placed on educating health care professionals, especially physicians and acute care nurses, that the quality of a person’s life is equally important and sometimes more important than just staying alive. These are the key people that can initiate the difficult conversations and provide the patient/family with the information they need to make informed decisions and choices about how they want to live their life.
You are so right! This is one of the key problems with Physician Assisted Suicide. Slowly and steadily, we need to re-educate to include all options for all patients.
I do believe that as we continue to put death on the table for discussion in society, that the individuals themselves will begin driving this particular conversation.
Great to hear from you. Sorry to be slow in responding. Because “life matters too” we took some time off and played in the summer sun! We enjoyed it fully!
Interesting to hear your comment that people who have access to HPC not considering physician assist suicide (PAS). I think there are people who receive the support of hospice palliative care who still request access to PAS. According to statistics, it seems that people often request access to PAS but if their symptoms are managed well, they rarely itilize the medications for PAS.
You mention the challenge of people dying in acute care with an emphasis on curative, without an appropriate switch to HPC services and support. THIs is such a difficult situation. Those of us who are experienced in Hospice Palliative Care cringe to think that this happens, and happens fars too frequently. And nurses in acute care often express their dismay when they witness this. A good lead up to “moral distress”.
Educating health care professionals is definately key to this. As the Baby BOomers age, this issue will continue to press the conversation.
Are you familiar with the Speak Up Campain with Canadian Hospice Palliative Care Association?
I think that it is really important that we stop using the term ‘physician assisted suicide’. Helping someone who is terminal hasten their death to avoid undue pain and ‘lack of quality of life’ is a very different matter to what we generally consider ‘suicide’ to be. Dying with Dignity (and other ‘right to die’ groups) have been using variations of ‘physician assisted dying’ — which has the implication that the person is already actually dying, and is being assisted by the physician (and possibly other support people) to do so in the easiest and safest way possible, and at an appropriate TIME for the Death Journeyer.
Great idea. The word “suicide” has connotations of individuals inflicting their own death, calling into question whether there is just cause. Removing the word “suicide” and replacing it with something like “dying” does indeed reduce the inflammatory nature of the phrase. Perhaps that is the next step in this process. Thank you for your invaluable insight.
Pashta, I think I put in another posting that I agree with your comment. Assisted Dying is perhaps a better term.
And I am not sure that the Physician is the only member of the team who should be in charge of this decision.
A further comment. The issue of euthanasia — as a different option to ‘physician assisted dying’ — definitely needs more in-depth discussion. There is rightful concern that it could be misused, in multiple ways. However, euthanasia (to my knowledge)is the only medium that a person has — while fully mentally capable — to declare that they do not wish to continuing living once they reach a specific stage (later ones) of dementia. The more medical interventions we develop, prolonging life, the more chance there is that a person will die with dementia — and particularly later stages of dementia.
I believe that a mentally capable person has the right to say that their ‘quality of life’ (or lack thereof) is not worth living once they reach an advance stage of dementia. But of course, at that point, they are not legally/mentally capable of requesting ‘physician assisted dying’. We need to make provisions for people to be able to define the stage of dementia in which they want their death hastened in their Advance Directives — and/or give the responsibility of the timing of ‘hastening death’ to their Representative (who, after all, is the person that THEY trust — not necessarily medical staff — to determine that ‘quality of life’ has been pasted/lost).
We need further clarity on the definition of euthanasia for this discussion. Without a very clear definition of the terms used, it is hard to respond to the issues.
In my understanding of the word, I think you are referring to Physician Assisted Dying/Suicide… vs euthanasia which can be completed without the consent of the dying person.
I am concerned about how people determine ahead of time when their life no longer has quality. It seems to me that many people adapt to the progressive losses, and seem to enjoy what they once did not think they would enjoy. It never ceases to amaze me how that changes.
Conversations, and attempts to understand what an individual wants… all so critical. But “definate determinants”… seem less certain to me.
This in from Cherlyn
“I Have been interested in a greener way to deal with my body after death and was interested in knowing differences between cremation and burial. I assume that cremation uses very large amounts of fuel. but is a simple shround or super biodegradable coffin available or legal in canada?
I do not have specific amounts of fuel required for cremation. I heard it was 80+ liters per cremation. Not sure of the type of fuel though, or the precise amount. That may not seem significant until you consider the numbers of cremation per year!
For traditional burials, a concrete vault is required before the body is placed in the grave. Again, this is not a lot of concrete per person, but add the total number of burials, and it is astounding. You can find out more about those total numbers on the green burial site.
In the Green Burial Cemeteries a biodegradable shroud or biodegradable coffin is necessary.
The wicker or grass coffin that I saw a while ago at First Memorial on display was beautiful. Reminded me of an old native papoose. Now I have the bed I want to die in (my outdoor bed) and my coffin (the grass one) to be buried in. Ready now to just carry on living fully! 🙂
Based on your questions, you might want to check out the Green Burial site, and if you want to connect with individuals who are very involved in Green Burial, please let me know and I can connect you.
This in from Ann-Marie
“I have to say I find this so very weird. You see I worked for over 10 years as a midwife doula, and now I work at a seniors facility and have thought seriously about palliative care so this is like the Universe talking directly to me, and my name is Annmarie too!!!
A great name huh! And I do believe that when we have feelings like this, it is probably important to listen. Sounds as if your background is a perfect match for exploring death doula/midwifery. Let us know what you decide.
Oh wow!!! Another Annmarie! “Our” Ann-Marie is exceptional!
I assume that you worked as a BIRTH midwife doula is that correct? And now you are working in seniors care? How interesting.
There is an increasing body of research and knowledge developing about Integrating a Palliative Approach in Long Term Care. Too often I fear that we forget that Long Term Care facilities are de facto hospices! The length of stay is getting shorter, in many cases it is less than 18 months for new admissions. In many facilities at least 50% of their residents die each year. And yet, as a society we do not provide the staffing and the support that it provided in a hospice setting. That really bothers me.
Health Ministries need to acknowledge the work of the Long Term Care facility and provide better financial support to facilities so the staff can do the work that is needed!