Medical Aid in Dying — report introduced in Quebec's National Assembly

Four days ago, Québec's National Assembly under the administration

 of the minority government of the Parti Québecois, brawt in a report

by an expert panel to allow some people to choose for medical 

assistance  to aid them in dying.  The bill is supported by all parties

in the government coalition.  The Québec government has set as

it's goal for enactment of the legislation sometime in the summer of

this year.  Ontario is quite another story; the government here in  the

hand of Liberal Party under Dalton McQuinty with support from the

opposition parties has ignominiously outlaws the very idea Death 

with Dignity to any practical extent, thus sadistically prolonging the

life of pain even of terminally ill persons without families to support

them spiritually and carefully.  The contrast between the two 

provinces is clear.  What approach the Federal government will take

remains to be seen and, perhaps, suffered.

— Albert Gedraitis

Dying with Dignity (Jan18,2k13)

An expert judicial panel appointed by the government of Quebec released their report this morning. Their report moves the province one step closer to legalized medical aid-in-dying by the summer of 2013.

Last March, as part of a comprehensive report on Dying With Dignity, the all-party committee of the Quebec National Assembly issued their full report (click here for English version), including recommendations to allow legalized end-of-life choice for individuals suffering greatly at end-of-life.

The government then appointed three expert lawyers to a judicial panel to make recommendations to the government on how to proceed with implementing these recommendations.

At issue is the fact that the right to medically-assisted dying is currently prohibited by the Criminal Code which is federal legislation and thus cannot be amended by any province. However, while the criminal law is set at a federal level, it is up to the provinces to write and administer healthcare legislation. Thus the panel recommends that Quebec introduce new healthcare legislation that will allow specific exemptions to the Criminal Code for doctors who provide medical assistance for someone to die.

Any exemption will be contingent on doctors following a strict set of guidelines so that the weak and vulnerable will also be protected.

The guidelines are very similar to those made in the Dying With Dignity Report: The Committee recommends that relevant legislation be amended to recognize medical aid-in-dying as appropriate end-of-life care if the request made by the person meets the following criteria as assessed by the physician:

• The person is a Quebec resident according to the Health Insurance Act;
• The person is an adult able to consent to treatment under the law;
• The person himself requests medical aid-in-dying after making a free and informed decision;
• The person is suffering from a serious incurable disease;
• The person is in an advanced state of weakening capacities, with no chance of improvement;
• The person has constant and unbearable physical and psychological suffering that cannot be eased under conditions he deems tolerable. 

Read the full report of the expert panel (in french) here.

The government of Quebec has repeatedly reaffirmed its commitment to allow medically-assisted dying by the summer of 2013. This bill will follow a report of the commission that has been supported by all government parties.

They are now one giant step closer.

Can Quebec do this? There are historical precedents. We do know that BC has already established prosecutorial guidelines that provide discretion to crown attorneys in bringing charges for assisting someone to end their life.  And Quebec was the first province to stop charging doctors for performing abortions - something they did 12 years before the legislation finally changed. It will be interesting to see the Federal response.
 

Death with Dignity: Trying to plan for the end of your life with facility and dignity

Bravo to New York Times for this editorial stance in favour of options which make Death with Dignity in a place and at a time I choose, more possible.  And another bravo to Gundersen Lutheran Health System in Wisconsin where "among the lowest-cost hospitals in the nation in treating patients at the end of life."

— Albert Gedraitis


NYT (Nov25,2k12)

EDITORIAL

Care at the End of Life

Published: November 24, 2012 159 Comments

Three years ago, at the height of the debate over health care reform, there was an uproar over a voluntary provision that encouraged doctors to discuss with Medicare patients the kinds of treatments they would want as they neared the end of life. That thoughtful provision was left out of the final bill after right-wing commentators and Republican politicians denounced it falsely as a step toward euthanasia and “death panels.”

Fortunately, advance planning for end-of-life decisions has been going on for years and is continuing to spread despite the demagogy on the issue in 2009. There is good evidence that, done properly, it can greatly increase the likelihood that patients will get the care they really want. And, as a secondary benefit, their choices may help reduce the cost of health care as well.

Many people sign living wills that specify the care they want as death nears and powers of attorney that authorize relatives or trusted surrogates to make decisions if they become incapacitated. Those standard devices have been greatly improved in recent years by adding medical orders signed by a doctor — known as Physician Orders for Life Sustaining Treatment, or POLST — to ensure that a patient’s wishes are followed, and not misplaced or too vague for family members to be sure what a comatose patient would want.

Fifteen states, including New York, have already enacted laws or regulations to authorize use of these forms. Similar efforts are under development in another 28 states. The laws generally allow medical institutions to decide whether to offer the forms and always allow patients and families to decide voluntarily whether to use them.

With these physician orders, the doctor, or in some states a nurse practitioner or physician assistant, leads conversations with patients, family members and surrogates to determine whether a patient with advanced illness wants aggressive life-sustaining treatment, a limited intervention or simply palliative or hospice care.

The health care professional then signs a single-page medical order telling emergency medical personnel and other health care providers what to do if the patient is incapacitated. In most states, the patient or surrogate must also sign the medical order to indicate informed consent. The orders are conspicuously highlighted in a patient’s electronic medical record and follow patients from one setting to another — such as a hospital emergency room or nursing home — so that any health professional handling the case will know what interventions the patient might want.

This comprehensive approach to end-of-life decisions started in Oregon in the early 1990s and is now used voluntarily by virtually all hospices and skilled nursing homes in that state. At least 50,000 Oregonians with advanced illness are covered by orders signed by a nurse or doctor. The program has provided care consistent with a patient’s wishes to limit treatment more than 90 percent of the time and has significantly reduced unwanted — and costly — hospitalizations, presumably reducing the overall cost of care.

The Oregon model has been adopted by the Gundersen Lutheran Health System in Wisconsin, where the forms now cover virtually all patients in facilities for long-term care or hospice care. Families are pleased and costs have come down. The Dartmouth Atlas of Health Care, which compares Medicare costs among various regions of the country, found that, in 2010, Gundersen was among the lowest-cost hospitals in the nation in treating patients at the end of life.

The Wisconsin Medical Society moved to organize voluntary pilot projects with doctors using Gundersen’s approach in other areas of the state. But the society backed down from using the physicians’ order forms because of opposition from the state’s Roman Catholic bishops, who contended that the orders might raise the risk of euthanasia. As a result, the pilot projects will only encourage healthy adults to do advance planning and create powers of attorney well before they face a medical crisis.

No matter what the death-panel fearmongers say, end-of-life conversations and medical orders detailing what care to provide increase the confidence of patients that they will get the care they really want. In some cases, that could well mean the request to be spared costly tests, procedures and heroic measures that provide no real medical benefit

.