Comment: Hastening death not part of palliative-care role

Though Dr. Adrian Fine is passionate and forthright (“B.C. off to a bad start with assisted dying” comment, March 9), I would like to respond to a couple of statements that he made, which I believe are incorrect.

Fine states that palliative-care physicians “are the most vocal opponents of assisted dying, claiming that palliative care obviates the need for assisted dying.” He goes on to say that “Canadian palliative-care physicians claim that none of their patients would choose this option,” accusing palliative-care physicians of being “disingenuous and paternalistic.”

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As head of the University of British Columbia Division of Palliative Care and being active in a number of national palliative-care organizations, I am familiar with many palliative-care physicians’ attitudes and beliefs around this difficult issue and would like to clarify our position.

Palliative-care physicians are at the forefront of managing patients with significant symptoms that affect their quality of life. We see firsthand how serious illnesses can lead to intense suffering for both the patient and their loved ones; in fact, we devote our working lives to relieving that suffering.

We also see patients in whom the suffering is emotional or existential rather than physical, and use teams of skilled professionals from all disciplines to try to address all aspects of suffering. We are well aware that for some patients, it is not possible to relieve suffering entirely, especially when it is related to functional loss or to existential concerns, rather than pain or other physical symptoms.

Though every physician might have his or her own personal feelings about whether they would be willing to provide hastening of death or not, Canada’s palliative-care physicians recognize that this choice is about to become legally respected, and the majority are supportive of eligible patients having access to it. Some have publicly advocated for this right.

The stance of palliative-care physicians toward physician-hastened death is not that of opposition, but about how we can best implement access to it in parallel with universal access to high-quality palliative care. Those patients whose suffering can be relieved by good palliative care should not instead ask a physician to hasten their death while being unaware of potentially effective treatments or supports.

Some believe that palliative care leads to an earlier demise than would otherwise be the case, despite clear evidence of the reverse being true. There are still many people who are strangers to the practice of modern palliative care and believe it is only appropriate when truly at the end of life, with only days or weeks to live. A large proportion of B.C. residents die from chronic progressive illnesses without any contact with a palliative-care service at all.

The World Health Organization definition of palliative care explicitly excludes hastening of death, so that patients can be reassured that their life will not be shortened by receiving palliative care. Early access to palliative care not only improves quality of life for patients, families and caregivers, but it has been shown in multiple studies to be associated with the same or longer survival than in those who do not receive such support.

Reluctance to access palliative care does not just come from patients and families; our colleagues are also often poorly informed in this regard, and many patients are referred for specialist palliative care very late in the course of illness, following much potentially preventable suffering.

If palliative-care physicians were to be seen as providers of physician-hastened death, the notion of how palliative care can benefit patients and their families might be overshadowed by fear of an accelerated demise, and those patients who just seek relief of suffering without hastened death might miss out on effective treatments.

It is also quite possible that provision of physician-hastened death could be perceived as a cheaper choice for the health-care system than providing quality palliative-care services.

Ideally, comprehensive and readily accessible quality palliative care should be made available to all patients diagnosed with a serious life-threatening illness, but as yet, a majority of Canadians do not have access to even basic palliative-care services.

A major investment in training of generalists is needed, as well as a significant increase in the number of palliative-care specialists, to care for those with the most complex conditions; to teach; and to drive research into finding the best ways of relieving suffering.

B.C.’s palliative-care physicians will not abandon their patients, and will continue to ensure they are provided with the best possible care up until their death (and then on for the family), irrespective of whether or not the patient chooses a physician-hastened death as their final act. They will continue working in partnership with all the other professionals, including providers of hastened death, as per their usual practice.

It is important, however, for patients not seeking a hastened death to know that palliative-care physicians do not consider this service to be part of their role.

 

Dr. Pippa Hawley is head of UBC’s Division of Palliative Care.

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