As a maternity doctor, Stefanie Green has been propped at the end of a bed as a husband tucks in behind his labouring wife and she gives one last push to deliver their child. As an assisted death practitioner, she has sat on the side of a bed as a wife took off her robe and slipped in beside her ailing husband to hold him one last time as they said goodbye.
Green, who has come to see both experiences as deliveries, says more than two decades as a maternity doctor prepared her well for her new career providing medical assistance in dying.
“I really find them very, very similar, moments,” said Green, who has assisted at more than 1,500 births and now more than 300 deaths. “At both deliveries, as I call them, I am invited into a most intimate moment in people’s lives.”
Green performed the first medically assisted death on Vancouver Island just days after the service was legalized in Canada in June 2016.
Now she has chronicled the first year of these bittersweet stories in her memoir This is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life, published by Scribner, a division of Simon and Schuster, and on bookshelves this week.
“Something profound is happening,” Green says. “I’m guiding it, I’m steering it. I’m making sure the right people are in the right place. And once I tell someone the heartbeat has stopped, I gently and quietly slip away and remove myself from the room.”
Afterwards she gathers her thoughts by walking along her favourite Oak Bay beach with her dog, hiking around the Island or paddling in her kayak.
“I picture Meg cradling Richard in their bed, and I believe that I have learned what love can look like,” writes 53-year-old Green, who is married to an astrophysicist turned entrepreneur and is the mother of two adult children.
On this day, Green, who started out as a family doctor, is in the waiting room of the same Fort Street office in Victoria where she counselled expectant mothers for much of her 22-year career. The walls are papered with snapshots of infants, many of whom she can still name. Those who now come to this same office to be assessed for medical assistance in dying say they like the lively air the baby photos bring to the exam rooms.
The average MAID patient is 75, though Green says she has assisted people age 27 to 105, referring to the latter patient as “quite a character.” She has assisted members and even leaders of all faiths. More than 65 per cent of those she helps have terminal cancer.
Green’s work gained international attention following a piece in the New York Times about the assisted death of former B.C. Government and Service Employees Union president John Shields, 78. The Oak Bay resident died in March 2017 at Victoria Hospice after being diagnosed two years earlier with a rare and incurable hereditary form of amyloidosis, a painful and disabling disease that would eventually see him lose use of his arms and legs and shut down his heart.
A civil rights activist and former Catholic priest who became a social worker, then union president who negotiated landmark pay-equity agreements, Shields decided days before his planned death to hold an Irish wake — replete with drink and Swiss Chalet chicken.
After the New York Times piece, a literary agent in New York approached Green to write a book on the early days of assisted dying.
In the book, Green tells the story of “free-spirit” Ed, 68, who on the day of his death chose to don a clown suit, red nose and colourful wig. Despite their many conversations, Green didn’t know he was an amateur clown. She rolled with it and alone with him in the room, she obliged by telling his favourite joke.
“I heard him chuckle,” writes Green. “Then he closed his eyes and fell asleep.”
In her early days of assessing people for medical assistance in dying, Green was plagued by the thought of risking up to 14 years in prison if she got anything wrong — an error in assessing a person for MAID, a complaint from an angry family member who opposed the patient’s choice, a mistake in procedure.
Writing about her first assisted death, Green says: “Harvey isn’t just my first assisted death. He is the first MAID death to proceed on Vancouver Island and among the first in all of Canada. I am aware I need to get this right — for myself, for the MAID program, but most importantly, for Harvey.”
At that time, Green was one of three providers in Victoria and five on the Island. Green took to ferries, propeller planes, highways and water taxis to assist patients across the Island and the province.
In the first four months of MAID, Island Heath was averaging six assisted deaths a month. In the first year, the Island was providing three times more than the national average.
People would seek out Green on their own because their family doctor “didn’t want to get mixed up” in MAID.
Green describes the “palpable” sigh of relief expressed by most clients when told they qualify for MAID, and the difficulty of walking away from others in intolerable pain because the law limited the procedure to people whose natural deaths were “reasonably foreseeable.” Few who are deemed eligible for MAID change their minds, she says.
“Once my patients were no longer fearful of how they might die, they focused intently on living and allowed themselves to more fully embrace the life they had left,” she writes.
Green triple-checks her paperwork, ensures patients know their options for palliative care, travels to each procedure early to enter at the exact minute she is expected, reviews the plan with the patient and gets their final agreement to proceed, and takes with her a back-up set of pharmaceuticals.
Most patients choose MAID by a series of injections delivered by a physician — the first medication is an anti-anxiety drug that puts the patient in a light sleep, followed by a local anesthetic, then a third drug, propofol, that puts the patient in a coma, and lastly a paralytic. The patient drifts off to sleep and usually during the third medication, breathing and the heart slowly stop. Patients also have the choice of taking a formulated drink, but few opt for this option.
Green says most people want to die as they lived — some choose rock music blaring, some prefer classical music lulling them to sleep, while others settle into the peace of silence. Many use the time in between to get their house and relationships in order.
Sometimes there is drama. In her book, Green tells the story of a grandmother who finally tells her grandson to “clean up your crap” before dismissing him from the room, and that of an adult daughter who, with just seconds remaining after the first anesthetic is injected in her mother, conveys words that haven’t been spoken in decades.
Green describes the bony hand of an 88-year-old mother on the “pale, smooth, steroid-induced cheeks” of her 67-year-old child with terminal cancer, saying her final goodbye.
After more than 40 assisted deaths, “it was the first time I felt tears that I simply could not hold back,” Green wrote.
“It’s impossible not to project myself into some situations,” Green says in an interview. “Some of them are excruciating. I mean, the concept of saying goodbye to your child is something … that takes my breath away … there’s too much — we all have a limit.”
Green also assisted a woman in her late 40s with whom she was acquainted. The woman was diagnosed with late-stage melanoma that had metastasized to her lungs, liver and brain. “I love you mommy” were the final words of the woman’s daughter as Green was set to administer the first needle. Green usually asks the patient to think of a favourite memory before they drift off to sleep. This woman said: “There are so many to choose from.”
Just before Ray, who was in extreme pain, died, he told Green: “I realize this might sound ridiculous, but I feel like you saved my life.” There are more uplifting stories than sad — like the family who sang “Who could ask for anything more?” from I Got Rhythm.
Woven through This is Assisted Dying is Green’s own story — what shaped the person who would choose to pioneer MAID, head up Canadian Association of MAID Assessors and Providers, and advise governments on how to improve legislation for medical assistance in dying.
Green talks about how her parents’ less-than-amicable divorce and subsequent marriages forced her to be independent and fend for herself. She explains how Judaism gave her a sense of belonging and a moral compass, and details how her role as a mother and wife required her to set boundaries in her new-found vocation.
Green hopes the book will stimulate conversations and reduce the stigma around addressing end-of-life decisions. It would take four years into her assisted-dying practice to broach her own last wishes with her husband. It took about the same time for her mother to make known her wishes for her death.
The government, meanwhile, is still sorting out eligibility for assisted death.
The law allowing it took effect June 17, 2016, but the government’s eligibility criteria said the eligible person’s natural death must be “reasonably foreseeable.”
In the years that followed, the criteria of “reasonably foreseeable death” proved problematic for assessors and providers. It was challenged in 2017 and 2019. As of March 17, 2021, the law no longer requires a person’s death to be “reasonably foreseeable.”
Instead, those wishing to receive MAID must “be in an advanced state of irreversible decline in capability and have enduring and intolerable physical or psychological suffering that cannot be alleviated under conditions the person considers acceptable,” according to the original decision.
Green says patients who can now access MAID include those with lifelong chronic pain or post-viral illness such as chronic Lyme disease or chronic fatigue syndrome (now called Myalgic Encephalomyelitis). “They would rather die than live like this,” said Green of these patients asking for MAID.
Green said there hasn’t been a rush of Canadians wanting to take advantage of the expanded access, and MAID providers are cautious about applying the expanded eligibility criteria.
The new law also opened up MAID to Canadians whose only medical condition is a mental illness — primarily in the area of psychiatry, such as depression and personality disorders — and who meet all other eligibility criteria, although the government has said that group will not be eligible for MAID until March 17, 2023.
A national expert review is now considering the protocols, guidance and safeguards for MAID for those suffering from mental illness and is expected to report its recommendations in April.
“We are all eagerly awaiting to hear what they say and then we’ll have another year to digest that and potentially implement that in March 2023,” said Green.
A joint parliamentary committee must still grapple with issues including whether to expand MAID access to advance requests — something that’s currently not allowed — and mature minors.
National polling suggests advanced requests is the priority issue for MAID, Green said.
“There are models of assisted dying that allow advance requests in other jurisdictions in the world that we can learn from, and I think that’s the debate and the conversation that Canadians want to have.”
Advance requests — for example, a person diagnosed with dementia or other competence-eroding condition who wants MAID if certain events happen — are a complicated issue, said Green.
In the book, she tells how people often explain the conditions under which they would want an assisted death — when they no longer recognize family members, for example.
Yet that raises many questions: Would the condition be met the first time a patient fails to recognize a family member? “The second time? When it’s consistent? Over how long a time period?”
Who would decide when the condition has been met? And what if that patient seems to be living comfortably in a specialized care facility, getting enjoyment out of small things, even if they are no longer the person they once were?
“Whose suffering should we take into account? The person who was or the person who now is? It’s simply not so simple.”
Six years into her new practice, Green is eager to tackle all these discussions. This is work she can do for a “long time,” she says.
While she says it’s far from lucrative and takes an emotional toll, she calls it “profoundly meaningful work.”
“Assisted dying is not so much about dying, right? It’s about how people want to live. It’s about what’s important to them, what brings meaning to their life, what brings joy to their life, what they have lost, what they still have.”
People who choose MAID choose the time and the day and the way they depart, and once that’s done, they no longer have to worry about dying and death, Green said.
“Immediately, once someone’s told that they have this option, that it’s available to them, it’s all about how they’re going to live the last bits of their life.
“To be able to offer this to someone in their final moments, it’s such privileged work.”
Assisted death timeline
Suicide was decriminalized in 1972, but in September 1993, the Supreme Court denied Victoria’s Sue Rodriguez, who had Amyotrophic Lateral Sclerosis, ALS, the right to a physician-assisted death.
In 2011, however, the case of Kay Carter of North Vancouver brought the matter to the fore again. Her lawyers argued the prohibition of assisted dying violated the right to life, liberty, and security of the person of grievously and irremediably ill patients.
Carter, 89, who had spinal stenosis causing intolerable suffering, travelled to Switzerland for an assisted death on Jan. 15, 2010. Then Gloria Taylor, 61, who had been diagnosed with ALS, joined the Carter case, arguing that if she didn’t have a physician’s help, she might have to end her life much sooner than she wanted, while she was still able-bodied, robbing her of her constitutional right to life.
In June 2012, Madam Justice Lynn Smith concluded a blanket prohibition against physician-assisted deaths breached a person’s constitutional rights.
A court of appeal overturned the ruling, but on Feb. 6, 2015, the Supreme Court of Canada ruled in favour of the B.C. Civil Liberties Association, Taylor and Carter’s family. The Carter decision allowed a competent adult suffering intolerably from a grievous and irremediable condition to ask a physician to assist them to die.