One out of two doctors who have turned down requests for medical assistance in dying by terminally-ill patients have probably done so without justification under the Quebec law, says the head of the province’s commission on end-of-life care.
“It’s 50-50,” Dr. Michel Bureau told the Montreal Gazette in an interview. “Are there some doctors who are too strict in the application of the criteria? We have observed this (attitude) in several cases.”
Despite the progress made in implementing the so-called dying with dignity law, some physicians continue to resist carrying out assisted dying, although in fewer numbers than when the legislation came into effect on Dec. 10, 2015, Bureau added.
In Montreal, the number of cases of physician-assisted dying is seven times higher in the east end than on the West Island, suggesting possible resistance by some doctors who are opposed to the practice for ideological or religious reasons.
The latest report by the commission does not specifically address the problem of physicians who are flouting the law. Instead, the report includes statistics on the “non-administration” of assisted dying.
For the first 28 months of the provincial law, 2,462 Quebecers made requests for physician-assisted dying. Of that number, doctors conducted the procedure on 1,632 individuals, delivering lethal intravenous infusions to patients who met specific criteria.
A patient must be at least 18 years old, suffer from a “serious, incurable illness,” be in “an advanced state of irreversible decline in capability” and be at the “end of life.” The individual must also “experience constant and unbearable physical or psychological suffering which cannot be relieved in a manner the patient deems tolerable.”
A total of 830 requests were not administered. There are several reasons for this. Some patients either died before their requests could be carried out (20 per cent) or they changed their minds (also 20 per cent). In yet another 20 per cent of cases, the patients fulfilled the criteria, but at one point in the 10-day period that is part of the assisted-dying protocol, they could no longer respond to the doctor.
The biggest-single category for non-administration was not meeting the medical criteria. A total of 191 patients, or 23 per cent, fell into that category.
Asked whether some doctors have refused a request on the pretext that the patient did not fulfill the criteria, Bureau replied that the ratio was 50-50.
The criteria for medical aid in dying is sometimes grey — not black or white.”
“The criteria for medical aid in dying is sometimes grey — not black or white,” he explained. “For example, is the patient’s suffering persistent and untreatable? There are some physicians whose interpretation of that criterion is very liberal and others who interpret it very strictly.”
Nonetheless, Bureau acknowledged, “there are some institutions in Montreal and across the province where there has been a resistance. I would say it’s a passive resistance.”
In April 2016, the McGill University Health Centre raised the ire of then-health minister Gaétan Barrette by transferring a patient who made an assisted-dying request from the palliative-care ward to another part of the hospital , causing an unnecessary delay.
Asked whether the MUHC is still showing resistance, Bureau replied: “In the beginning, we observed a certain resistance, but less so now. The difficulty with these institutions is to find enough doctors who will volunteer to provide assisted dying.”
Dr. Georges L’Espérance, president of the Association québécoise pour le droit de mourir dans la dignité, blamed mostly palliative-care specialists for the continued opposition.
“On the island of Montreal, the figures show that there is a problem that is essentially one of ideological resistance, which exists at the CHUM (Centre hospitalier de l’université de Montréal) and more so at the MUHC,” L’Espérance said.
“Certain palliative-care specialists do perform assisted dying, especially in the regions, as well as some in Montreal. However, a majority — especially at the MUHC, McGill and CHUM — are rather opposed to assisted dying.”
Dr. Balfour Mount is credited with pioneering palliative care in North America, founding a unit in 1973 at the former Royal Victoria Hospital (now part of the MUHC) that was dedicated to easing the pain and suffering of the terminally ill. Today, some palliative-care specialists argue that administering a lethal infusion at the patient’s request is against their medical ethics.
“In the beginning of the (Quebec law), there was a certain confrontation between palliative care and medical aid in dying,” Bureau recalled. “It was viewed as palliative care versus assisted dying.
“Doctors were not trained to put an end to life, and they’ve been resistant to that,” he added.
However, Bureau and L’Espérance contend that assisted dying is part of a continuum, which starts with palliative care.
They don’t want to suffer another three months and they’re asking for medical aid in dying.”
“It’s the palliative-care patients who are saying at a certain point that even though they’re receiving good palliative care, they don’t want to suffer another three months and they’re asking for medical aid in dying,” Bureau said.
And contrary to the assertion by some that assisted-dying requests arise mostly from patients who do not have access to palliative care , the commission found that the opposite is true.
Take, for example, the health authority responsible for the city’s east end, the CIUSSS de l’e st-de-l’Île-de-Montréal, which includes Maisonneuve-Rosemont Hospital. That CIUSSS treated 9,800 patients in palliative care from Dec. 10, 2015 to March 31, 2018 — by far, the highest number for any health authority in Montreal.
Of those in palliative care at the CIUSSS, 104 patients sought assisted dying — again, by far the highest number in Montreal.
By comparison, the West Island CIUSSS, which includes the Lakeshore General Hospital, treated 2,868 patients in palliative care during the same period. Of that number, 14 ultimately chose assisted dying.
The CIUSSS de l’e st-de-l’Île employs 15 physicians in palliative care, according to the latest figures. The West Island CIUSSS has 11 physicians in its palliative-care program.
The CIUSSS de l’e st-de-l’Île budgeted nearly $5.7 million for palliative care in its last fiscal year, while officials at the West Island CIUSSS were unable to provide any figures to the Montreal Gazette.
“If the entry (into palliative care) is small, the number of cases of assisted dying will be small, too,” Bureau said.
80 per cent had terminal cancer
Given that nearly 80 per cent of all patients who have died from assisted dying have suffered from terminal cancer, one would expect that the city’s cancer centres would report a high number of patients seeking the end-of-life procedure.
Yet, the west-central Montreal CIUSSS, which includes the Segal Cancer Centre, reported 20 cases of assisted dying. The MUHC, which houses the Cedars Cancer Centre, reported 31 such cases. Bureau attributed those lower numbers to the initial resistance by palliative-care teams in those two institutions.
The CHUM, which also has a cancer centre, reported 56 cases of assisted dying, almost half the number at the east-end CIUSSS.
Although it might be tempting to ascribe some of the discrepancies to linguistic differences between English-speaking and francophone hospitals, both Bureau and L’Espérance argued that language has nothing to do with it.
Bureau noted that the medical team at the east-end CIUSSS started preparing for assisted dying a year before the law came into effect. Today, in addition to palliative-care specialists, oncologists and neurologists at that CIUSSS perform assisted dying — a model that Bureau recommends should be emulated across the province.
Despite the lingering resistance, Bureau said demand for physician-assisted dying has been growing each year . Ultimately, he predicted that much of the remaining opposition will fade away as future generations of physicians embrace the concept.
Copyright Postmedia Network Inc., 2019