james downar, mdcm, mhsc (bioethics), frcpc objectives ... · douglas et al. med j aust...
TRANSCRIPT
Slide 1
Physician-Assisted Death in Canada:Where we are, where we are going
James Downar, MDCM, MHSc (Bioethics), FRCPCCritical Care and Palliative Care, UHN
Associate Professor, Department of Medicine, University of Toronto
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Slide 2 Objectives
• Enhanced knowledge of the experience with physician-assisted death in other jurisdictions.
• Skills to balance conscientious objection with the right of access.
• Attitudes and/or awareness of the challenges confronting the medical community in a country where physician-assisted death is legal.
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Slide 3 Disclaimers
• I have an opinion (we all do)
• Former co-chair of Physicians’ Advisory Committee of Dying with Dignity
• PAD = Physician-Assisted Death•Physician-Assisted Suicide
•Euthanasia
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Slide 4 “I'm not afraid to die, I just don't want to be there when it happens.”
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Slide 5 The Data: What is the effect on…
• …vulnerable populations?
• …non-voluntary ending of life?
• …Palliative Care?
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Slide 6 Can we protect the vulnerable?
Characteristic Washington Oregon
Number 255 935
Age 85+ 15% 11.9%
White 95.2% 97.6%
High school graduate 94.1% 93.2%
No health insurance 2.7% 1.7%
EOL concerns
Loss of autonomy 90.6% 90.9%
Inability to engage in enjoyable activities 88.6% 88.3%
Burden on family 38.6% 36.1%
Financial implications of treatment 4% 2.5%
Loggers et al. NEJM 2013;368:1417-24.
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Slide 7 Can we protect the vulnerable?
• Demographics of Swiss receiving Assisted Death
– Higher income
– Higher education
– Non-institutionalized
Characteristic Logistic Regression Odds Ratio (Age 65-94)
Education
Compulsory 1
Secondary 1.74
Postsecondary 2.71
Type of Household
2+ People 1
1 Person 1.44
Institutionalized 0.84
Socioeconomic Position
Lowest Quartile 1
Second Quartile 1.36
Third Quartile 1.90
Highest Quartile 2.68
Steck et al. Int J Epidemiole-published Feb 18, 2014
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Slide 8 Non-voluntary ending of life
• Assisted Death in the Netherlands
End of Life Decision-Making. Royal Society of Canada, 2011.Onwuteaka et al. Lancet 2012;380:908-15.
1990 1995 2001 2005 2010
VoluntaryEuthanasia
1.7% 2.4% 2.6% 1.7% 2.8%
Assisted Suicide 0.2% 0.2% 0.2% 0.1% 0.1%
Life-terminatingacts without explicit request (LAWER)
0.8% 0.7% 0.7% 0.4% 0.2%
Total 2.7% 3.3% 3.5% 2.2% 3.1%
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Slide 9 Does prohibition of PAD prevent LAWER?
Van der Heide et al. Lancet 2003;362:345-50.Mitchell and Owens. N Z Med J 2004;117:U934.Douglas et al. Med J Aust 2001;175:511-5.
• Visibility is a better safeguard than criminalizationCountry LAWER Assisted Death
Australia 3.5%
Belgium (pre-legal) 3.2%
New Zealand 2.7%
Belgium (post-legal) 1.7%
Denmark 0.67% 1.82%
Switzerland 0.42%
Netherlands 0.4%
Sweden 0.23% 0.23%
Italy 0.06% 0.1%
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Slide 10 Does PAD replace PC?
Cause of Death
2001 2005 2010
Cancer 7.4% 5.1% 7.6%
CV Disease 0.4% 0.3% 0.5%
Other 1.2% 0.4% 1.1%
TOTAL 2.8% 1.8% 3.0%
Cause of Death
2001 2005 2010
Cancer 33.4% 37.1% 47.7%
CV Disease 11.1% 14.3% 21.5%
Other 17.1% 24.1% 36.0%
TOTAL 20.1% 24.7% 36.4%
Physician Assisted Death
“Intensified Alleviation of Symptoms”
(Netherlands)Onwuteaka et al. Lancet 2012;380:908-15.
16%
0.2 %
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Slide 11 Does PAD replace PC?
EOL Practice 1998 2001 2007 2013
“Palliative Care” 34.8% 44.8% 58.6% 53.2%
“Intensified Alleviation of Symp.” 18.4% 22.0% 26.7% 24.2%
WHLS/WDLS 16.4% 14.6% 17.4% 17.2%
Continuous Deep Sedation -- 8.2% 14.5% 12.0%
Physician Assisted Death 4.4% 1.8% 3.8% 6.3%
Euthanasia 1.1% 0.3% 1.9% 4.6%
Assisted Suicide 0.12% 0.01% 0.07% 0.05%
LAWER 3.2% 1.5% 1.8% 1.7%
Chambaere et al. NEJM 2015;372:1179-81.
19%
1.9%
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Slide 12 Effect of PAD on EOL Care
Economist Intelligence Unit, 2010
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Slide 13 Effect of PAD on EOL Care
• Availability of PC in US hospitals (2015)
1. Vermont (100%) - A
2. New Hampshire (100%) – A
3. Montana (100%) – A
4. Washington (93%) – A
5. Nevada (92%) – A
6. New Jersey (91%) – A
7. Rhode Island (89%) – A
8. South Dakota (89%) – A
9. Oregon (89%) – A
10. Massachusetts (88%) – A
11. Wisconsin (88%) – A
…
23. California (74%) – B http://www.capc.org/reportcard/topten
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Slide 14
• Compared with UK (2002-2011)…•…Belgium had similar growth of PC (12%/yr)
– Home care
•…NL and Luxembourg had dramatically higher growth in PC resources, beds
Chambaere K, Bernheim JL. J Med Ethics 2015;41:657–660.
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Slide 15 What do we still need to do?
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Slide 16 Carter vs. Canada AG (SCC 2015)
• Unanimous decision•S. 241(b)- Aiding and abetting suicide
•S. 14- Consenting to have death “inflicted”
• Rationale• Section 7: Life, liberty and Security of the Person
• NOT CONSIDERED- Section 15: Equal protection without discrimination (physical disability)
• Decriminalized both assisted suicide and voluntary euthanasia
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Slide 17 Carter vs. Canada AG (SCC 2015)
• Competent adult who:
– Clearly consents to the termination of life
– Has a grievous and irremediable medical condition (including an illness, disease or disability)
– Enduring suffering that is intolerable to the individual in the circumstances of his or her condition.
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Slide 18 Bill 52 (Law 2)
• Indication• At EOL, serious and incurable illness• Advanced state of irreversible decline in capability• Constant and unbearable physical or psychological
pain
• Adult, resident x3 months• Competent written request, confirmed orally
after “reasonably spaced interval”• Confirmed by independent physician
(witnessed)• MD must be present throughout PAD
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Slide 19 Bill C-14
• Competent adult (> age 18)
• Grievous and irremediable medical condition
•Serious and incurable illness/disease/disability
•Advanced state of irreversible decline in capability
•Enduring physical/psychological suffering, cannot be relieved under conditions they consider acceptable
•“natural death has become reasonably foreseeable”
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Slide 20 What is reasonably foreseeable?
• Does anyone with a grievous and irremediable illness not have a reasonably foreseeable death?
• Does everyone have the same judgment?
• Could this provision violate Carter?
• Do we want to limit PAD to situations where the patient is “dying” already?
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Slide 21 Vital questions
• What will be the indications for PAD?
• How specifically do we improve PC?
• Who will manage the oversight/safeguards?
• How do we train physicians and allied health to perform PAD?
• How do we balance the right of access with the right of conscientious objection?
Downie J. CMAJ 2015
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Slide 22 What are indications for PAD?
• Physical suffering?•What is “intolerable”?
• Psychological suffering?• Indication or contraindication for PAD?
•Rational suicide?
• Different standards for terminal/non-terminal illness?
Ho AO. Can J Psychiatry 2014;59:141-7.
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Slide 23 What safeguards should we use?
• How many physicians should ensure capacity? Non-physicians?
• How do we ensure persistence of request?
•14-15 days (Oregon, Bill C-581)
•“Reasonably spaced intervals” (Bill 52)
•Nonterminal?
• Other therapeutic possibilities?•Palliative care consultation?
•Psychiatric assessment?
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Slide 24 Oversight
• Review committees•Rate of reporting?
•Feedback?
•Notification of authorities?
•Empowerment of committee?
• Reporting mechanism•Voluntary submission
•Monitoring of prescription
•Monitoring of dispensing medication
• Inpatient facility
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Slide 25 Oversight
• Judgment of Commissions
– Belgium- 8 MDs, 4 lawyers, 4 PC practitioners
– Holland- 1 MD, 1 lawyer, 1 ethicist
– Bill 52- 11 representatives appointed after consulting college of physicians, nurses, pharmacists, social worker/marriage therapists, notaries, plus representatives from institutions, ethics community, and patient advocate
Smets et al. Health Policy. 2009;90:181-7.
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Slide 26 Oversight – Bill 52
• 2/3 vote would trigger feedback to MD, notification of institution and/or College des Medecins for “appropriate measures”
•0 cases referred in Belgium
•16 cases (0.2%) in Netherlands from 2003-6
•Medical act vs. Criminal act
Smets et al. Health Policy. 2009;90:181-7.
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Slide 27 Issues for Psychiatry
• Capacity in patients with mood disorders•“Inherent mental factors that limit choice should
not deprive a person of access to appropriate medical treatments ….. that may alleviate suffering.”
• Should all PAD cases be referred?
• Is there such a thing as “irremediable” depression or anxiety?
1Neilson, G. et.al. The Canadian Journal of Psychiatry, Vol 60 No. 4 2015Gratitude to Dr. Derryck Smith
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Slide 28 Depression in PC and PAD
• Half of patients in NL requesting PAD have depression
• 27% of patients receiving PAD in Switz had depression
• Review of 8 palliative care programs in Canada
• 12.2% had a genuine desire to die• 52.2% of these had a mental disorder
• 58 patients in Oregon with either cancer or ALS who had requests for PAD
• 15 had depression, 15 had anxiety disorder
Levene, I. J. Med. Ethics 2011: 37: 205-211Wilson, K.G. et.al. BMJ Supportive & Palliative Care 2014: 0:1-8Ganzini, L. et.al. BMJ 2008, 337Gratitude to Dr. Derryck Smith
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Slide 29 Mental Illness and PAD
• Review of the first 100 patients from Belgium with request for PAD based solely on psychological suffering:
•Depression - 58
•Personality Disorder - 50
•Asperger’s Syndrome - 12
• 48 accepted for PAD
• Only 3% of all PAD cases in Belgium had a primary psychiatric disorder
Thienpont, L. et.al., BMJ Open 2015 Gratitude to Dr. Derryck Smith
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Slide 30 Canadian Psychiatric Association
• “…does not recommend that psychiatrists be involved in the procedures of prescribing or administering lethal doses of medication.”
• Should be involved for cases of mental illness but not routinely for other cases
• “Rarely if ever should [mental illness] be considered ‘irremediable’ regarding interventions aimed at addressing psychosocial stressors for a person with mental illness.”
CPA Submission to External Panel on Options for a Legislative Response to Carter v. Canada
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Slide 31 Conscientious Objection
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Slide 32 Conscientious Objection in 2013
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Slide 33
http://www.withoutamanual.com/gallery.html
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Slide 34
http://www.withoutamanual.com/gallery.html
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Slide 35 Reasonable Accommodation
• Physician Autonomy Wins
Patients only get what I think is “moral”
• Patient Autonomy Wins
All physicians must provide everything
• Finding middle ground- Pluralistic society
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Slide 36 Reasonable Accommodation
• Minimal impingement on others’ rightsNo “right” to zero discomfort
• Pts accommodate MD right to object
Delay, inconvenience, suffering
• MDs accommodate Pts desire for PAD
Referral to other MD, agency?
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Slide 37 Reasonable Accommodation
•What does “inform” mean?•What would you reasonably expect a
terminally-ill, suffering, bedbound patient to do without assistance?
•What does “refer” mean?•How is this different from transferring?
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Slide 38 Reasonable Accommodation
• Institutional Conscientious Objection– Moral Pain?– Why would we need it?– Who decides the morals of a public hospital?
• Obligations to the patient– Shared between practitioner and institution– Minimal impingement– Cannot be defined by a single action
• Illness, Social function, Technical facility, Geography
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Slide 39 Integrate PAD into EOL
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Slide 40 Look at some numbers…
• What % of palliative pts will support PAD?
Support PADDon’t
Support PAD
Ipsos-Reid Poll, Oct 2014
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Slide 41 Look at some numbers…
•In Oregon, PAD accounts for 0.2% of all deaths
–…90% of pts receiving PAD enrolled in hospice
–...36% of pts receiving PAD prescription never take it
•PAD will mostly occur among patients receiving PC
–Many will ask about PAD, few will pursue it
–Many will change their minds, even at a late stage
Loggers et al. NEJM 2013;368:1417-24.http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/DeathwithDignityAct/Documents/year16.pdf
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Slide 42 Look at some numbers…
•Many PAD requests are not granted/rejected
–55% not granted in Netherlands
–23% not granted in Belgium
•Right-to-Die NL Clinic- First year outcomes
–25% of clients received PAD
Onwuteaka et al. Lancet 2012;380:908-15.Chambaere et al. NEJM 2015;372:1179-81.Snijdewind et al. JAMA Int Med Online Aug 2015
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Slide 43 Integrate PAD into EOL
• People routinely pick PC over PAD– Vast majority of PC patients want the option of PAD
– Most patients who ask about PAD will not use it
• Many/most PAD requests are not granted
• People change their minds about PAD, even very late
• If you want pts to pick PC over PAD, make sure PC is always easily available to pts seeking PAD
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Slide 44 Objectives
• Enhanced knowledge of the experience with physician-assisted death in other jurisdictions.
• Skills to balance conscientious objection with the right of access.
• Attitudes and/or awareness of the challenges confronting the medical community in a country where physician-assisted death is legal.
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