Quebec doctors open door to euthanasia

[rmorelan]

Looks like what is normally a very abstract debate is about to be thrust back into the spotlight! I think our next ethics class is about to become more heated.

 

http://www.thestar.com/news/canada/article/720360--quebec-doctors-open-door-to-euthanasia?bn=1

 

Now the bill they mention is unlikely to pass, but the formal position of the college is interesting.

[future_doc]

I think they would like to legalize the de facto situation that already exists that they will never admit is now actually happening (b/c it is illegal). When an overwhelming majority are in favour of such an important issue, it is not just a coincidence that so many just happen to be in agreement.

[leviathan]

There's a difference between physician assisted suicide and euthanasia. The former is when you provide the means for the patient to take the final step to end their own life (e.g. by prescription of certain medications). The latter is when the doctor makes the final action that leads to the patient's death. Physician-assisted suicide is already legal in Oregon, Washington State, and I believe also Idaho. It is only approved for people with terminal illness that is refractory to aggressive pain management, there is a waiting period of 2 weeks before the prescription is filled, and the patient has to make multiple requests. I think multiple doctors have to sign off on it, too, and of course the patient has to be competent and not suffering from depression or other mental illness.

 

For some reason, Canada is still lagging behind when we're supposed to be more liberal and progressive! Hopefully this will change soon...

[future_doc]

What about an elderly patient, unconscious, on the respirator, with an unfavourable prognosis? Do the physicians have the right to pull the plug? And if they don't have the right and do it anyways (whether they consult the family or not)?

[NLengr]

Physicians are allowed to refuse to provide care that is medically futile.

 

For example, if a family of a 90 y.o. man with metastatic Ca who is going into renal failure while in a coma wants to give him dialysis, the physicians can refuse on the basis that it is medically futile.

 

The trick is defining medically futile.

[Star1234]

What about an elderly patient, unconscious, on the respirator, with an unfavourable prognosis? Do the physicians have the right to pull the plug? And if they don't have the right and do it anyways (whether they consult the family or not)?

 

I assume that by "pull the plug", you mean take them off life-support, which is different from euthanasia. By pulling the plug, the physician is not actively doing something to cause the patient to die but is instead withholding treatment, which are 2 very different things.

 

I believe the rule is that if the patient is unable to make the decision about whether to be taken off life-support or not, then the decision lies in the hands of the family regardless of the prognosis. If the physician does pull the plug without the consent of the family, then they can be in big legal trouble. I believe the only exception to this is if the patient is brain dead...

 

Someone correct me if I'm wrong.

[future_doc]

Medically futile brings an interesting perspective NL.

 

Yes Star, you understand what I meant in regard to "pull the plug". I am aware of a situation at a teaching hospital where that is exactly what was done to an 83 yr old who likely would have died within a week anyhow. The physician did not consult or inform family, merely acted, when a family member from out of town who was in Montreal and call ed the hospital, he was told, "you had better co0me soon as we pulled the plug". The patient was not brain dead, they just did it. I understand the big picture, he was going to die anyhow, zero quality of life at this point in time, unconscious or semi-coma state, shortage of beds, overabundance of waiting patients, I get it. The family did not raise any issues, they might have even agreed if asked.

 

With my limited understanding, I believe technically this is "murder". However, I also believe these such decisions are taken every day. It is a difficult situation for eveybody involved, including society, so people choose to ignore the de facto situation as it exists, and the physician is left to make hard choices sometimes with nowhere to turn and certainly, no legal protection. I think this may have influenced the recent high approval or support to which rmorelan referred.

[Star1234]

Well, it's not really "murder" if the doctor is just withholding treatment. This actually happens a lot....for example, stopping dialysis is the second leading cause of death in patients with End Stage Renal Disease in Canada.

 

Taken from the book "Doing Right":

 

"Refusing medical intervention merely allows the disease to take its natural course; if death were eventually to occur, it would be the result, primarily, of the underlying disease, and not the result of a self-inflicted injury".

 

Although I do agree with you that the physician should have asked for the permission of the family first.

[rmorelan]

Well, it's not really "murder" if the doctor is just withholding treatment. This actually happens a lot....for example, stopping dialysis is the second leading cause of death in patients with End Stage Renal Disease in Canada.

 

Taken from the book "Doing Right":

 

"Refusing medical intervention merely allows the disease to take its natural course; if death were eventually to occur, it would be the result, primarily, of the underlying disease, and not the result of a self-inflicted injury".

 

Although I do agree with you that the physician should have asked for the permission of the family first.

 

Yeah is the permissions thing - Doctors shouldn't ever decide to unplug a patient. The patient should, or if not possible the person put in charge of the patient by their own actions via a power of attorney or by default those appointed by law - generally their family. Otherwise is overstepping a line I think.

 

In this case the patient did not refuse treatment, so that particular section from doing right does not apply.

[future_doc]

Not only should physicians understand the legal and ethical implications (and exposure/risk) of their actions, some need to learn to act with sensitivity, not only for the sake of the patient, family and others, including health care workers, but to protect themselves. For example, in this case, obviously the physician did not personally pull the plug, rather a nurse would have done that; and I have not the solightest idea what the hospital chart would show.

 

It would be best for all that there were clear guidelines and a protocol established. And this should be part of medical curriculum, is it? Doctors should not be exposed or expose themselves to civil and/or criminal proceedings in such matters.

[Star1234]

Actually that quote from "Doing Right" was taken from Ch.11 which dealt with end-of-life decisions (and whether the physician had the right to refuse medical intervention on the part of the patient, not whether the patient had the right to refuse medical treatment, which is another thing).

 

Also, doesn't the CMA publish an updated code of ethics every once in awhile where physicians can look up what to do in sticky situations?

[future_doc]

hmm, in this case I think it would not be so much 'refusal' as 'interruption' and 'termination' of ongoing medical intervention which could have only one result.

 

I would love to read the CMA code of ethics on this topic.

[A-Stark]

Not only should physicians understand the legal and ethical implications (and exposure/risk) of their actions, some need to learn to act with sensitivity, not only for the sake of the patient, family and others, including health care workers, but to protect themselves. For example, in this case, obviously the physician did not personally pull the plug, rather a nurse would have done that; and I have not the solightest idea what the hospital chart would show.

 

It would be best for all that there were clear guidelines and a protocol established. And this should be part of medical curriculum, is it? Doctors should not be exposed or expose themselves to civil and/or criminal proceedings in such matters.

 

I don't know why you think such policies don't exist. ICUs even have wall posters describing policies and information about end-of-life discussions.

[leviathan]

That's an interesting debate. Generally, physicians do not have to provide care that is medically futile, which in that case it seems it was. However, there's something to be said about respecting the family's wishes too in a case like that. When I think of refusing to do medically futile acts, I'm thinking it has to do more with harmful things like CPR in a patient with terminal illness.

[future_doc]

I don't know why you think such policies don't exist. ICUs even have wall posters describing policies and information about end-of-life discussions.

 

I understand what you say but find it difficult to wrap my head around the appropriateness of the facts I described. Strictly speaking, I do not know that the decision and execution of it was correct or legally proper in the manner in which it was done, by experienced health care professionals. And there is no reason why physicians should expose themselves and those acting under their authority to potential dire legal consequences for the lack of implementation of a clear and coherent policy if one does exist in every hospital. As always, the devil is in the details.

 

leviathan has added clarity with Post # 17 below.

[future_doc]

That's an interesting debate. Generally, physicians do not have to provide care that is medically futile, which in that case it seems it was. However, there's something to be said about respecting the family's wishes too in a case like that. When I think of refusing to do medically futile acts, I'm thinking it has to do more with harmful things like CPR in a patient with terminal illness.

 

I get your point about not providing care that is medically futile.

 

However, once commenced, is it ethically and legally proper to pull the plug? The theoretical harm in this case was the hastening of the death of a patient who would have died very soon in any event. Sensitivity of family is an entirely other matter, although issues could have been joined had, for example, the family registered a formal complaint with the hospital, doctor, College and/or police.

 

Would the physician and nurse who implemented his orders have a valid defence if charges were brought or they were brought before their respective licencing authorities? I recall the extreme case of Katrina where patients could not be removed to higher ground as water was rising, decisions were taken for the compassionate deaths of the patients and criminal charges were laid. Physicians should not be placed in such positions by society or b y virtue of their own decisions.

[leviathan]

I get your point about not providing care that is medically futile.

 

However, once commenced, is it ethically and legally proper to pull the plug? The theoretical harm in this case was the hastening of the death of a patient who would have died very soon in any event. Sensitivity of family is an entirely other matter, although issues could have been joined had, for example, the family registered a formal complaint with the hospital, doctor, College and/or police.

It is legal to do so, and with the family's consent, I think also ethical to do so. This is classified as 'passive euthanasia', and the courts have ruled it is legal in both Canada and the US.

 

Would the physician and nurse who implemented his orders have a valid defence if charges were brought or they were brought before their respective licencing authorities? I recall the extreme case of Katrina where patients could not be removed to higher ground as water was rising, decisions were taken for the compassionate deaths of the patients and criminal charges were laid. Physicians should not be placed in such positions by society or b y virtue of their own decisions.

Yes they would have a valid defense, absolutely. Katrina was a different story because they were actively euthanizing the patients, not just withdrawing care (passive euthanasia). I don't remember if they actually ended up getting charged or not?

[future_doc]

leviathan, thank you for your clarifications.

[LSE.IHP(HE)]

This is a highly recommended article from the NY Times providing some insight and context to the Katrina case ...

 

http://www.nytimes.com/2009/08/30/magazine/30doctors.html?_r=1

[future_doc]

I found the article fascinating until blank pages turned up at page 4.

[moo]

Unfortunately, in Canada, we tend to give up too easily on life. Whenever an elderly patient is admitted, we rush to get them or their family to sign the DNR form. While it is important that we know what to do in cases of cardiac arrest or respiratory failure, I think at times we pressure family and patients into signing. Elderly patients can bounce back, and they can bounce back quite quickly.

 

As an example, I once had (and still have) a nursing home patient who started deteriorating quickly. I wasn't on call that weekend but my colleague ended up transferring her to acute care. The only thing wrong with her was that she was a bit hyponatremic. Her labs stabilized, she was fluid resuscitated but she was still out of it. I made the decision to transfer her back to the nursing home as we weren't doing anything more for her in acute care. Over a period of a couple weeks, her husband was very upset about the fact that she was like a vegetable, wanted us to effectively let her die (not to feed her, not to give her fluids, etc). I told him not to give up hope, that people can bounce back, etc. Well lo and behold a week later, she started slowly getting better. She is back to her baseline now and the husband is very grateful that we did not give up on her.

[future_doc]

You make a huge difference moo, so glad you chose medicine and med chose you!

[The_B]

Unfortunately, in Canada, we tend to give up too easily on life. Whenever an elderly patient is admitted, we rush to get them or their family to sign the DNR form. While it is important that we know what to do in cases of cardiac arrest or respiratory failure, I think at times we pressure family and patients into signing. Elderly patients can bounce back, and they can bounce back quite quickly.

 

I don't know that this is a fair comment to make. I think there is a huge disparity on what we do and how much work we put into cases. I've been involved in cases, where the opposite is definitely true. We do way to much. Using literally boxes of blood for a patient who's been down for hours, and showing signs of DIC. Or the patients who repeatedly come back to hospital with severe congenital malformations and likely will not survive much longer and certainly without any quality of life, who get 1 on 1 nursing care and are full code. I think it is impossible to make even generalized comments about how much we do or don't give up on life.

[future_doc]

Quebec Debate on Euthanasia see:

 

http://www.cmq.org/en/medias/profil/commun/Nouvelles/2009/~/media/208E2B537FB144FAAE33DEB458D3AA90.ashx?120904

 

see also: http://www.cbc.ca/canada/monteal/story/2009/11/03/quebec-pysicians-euthanasia.html

 

http://www.cbc.ca/cp/health/091203/x120311A.html

[future_doc]

http://www.thestar.com/news/canada/politics/article/1315329--quebec-legal-panel-supports-medically-assisted-death

 

Quebec legal panel supports medically assisted death

QUEBEC—A panel of legal experts in Quebec is recommending that people suffering from an incurable or degenerative illness be allowed to ask for medical assistance to help them die.

 

However, the panel says the final decision should be left up to doctors.

 

Tuesday’s recommendations follow a landmark report in Quebec from last March that suggested doctors be allowed in exceptional circumstances to help the terminally ill die if that is what the patients want.

 

The report opened the door to euthanasia, which is specifically called medically assisted death.

 

Euthanasia and assisted suicide are illegal in Canada under the Criminal Code.

 

Quebec’s junior health minister, Véronique Hivon, said Tuesday’s legal opinion paves the way for the province to table a bill on the controversial topic in the next few months.

 

It’s a debate that Canadians have grappled with for nearly two decades.

 

In June, Justice Lynn Smith, of the B.C. Supreme Court, ruled that current right-to-die laws are discriminatory and unconstitutional. She said the law’s provisions “unjustifiably infringe on the equality rights of Gloria Taylor and the rights of life, liberty and security of the person.”

 

In her ruling, Smith granted Taylor, 64, a constitutional exemption to proceed with physician-assisted suicide. However, no one else can avail of the exemption. She placed a 12-month suspension on her ruling to give Parliament time to write new legislation, or for the anticipated appeals.

 

In 1992, assisted suicide hit the national radar when Sue Rodriguez, a B.C. woman, fought all the way to the Supreme Court of Canada for the right to kill herself. Rodriguez, who suffered from Lou Gehrig’s disease, lost 5-4 in a split decision. She killed herself in 1994 with the help of an unidentified physician.