How doctor assisted death is changing in Kingston

New legislation causes changes at Kingston General Hospital and Queen's

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A lengthy legal process reached a conclusion in June when Bill C-14 made medically assisted death legal in Canada.

Kingston General Hospital (KGH), located on the south side of Queen’s campus was one of the first hospitals in the country to begin carrying out the legislation. 

There’s a set of concrete rules listed in the legislation regarding how a patient can receive their doctor’s assistance in dying. Only physicians and certain nurses are legally able to administer medically-assisted death and only based on specific circumstances.

In Ontario, the patient has to be at least 18 years of age, have an OHIP card and death of the patient without assistance must be in the foreseeable future.

Due to the recent nature of the law, the decision of who qualifies for it and how it’s to be done according to the legal parameters, is mostly left up to a doctor’s discretion, according to Allan Hammond, chair of the Kingston chapter of Dying with Dignity Canada.

Dying with Dignity is “a national organization committed to improving quality of dying, expanding end-of-life choices and helping Canadians avoid unwanted suffering”, according to thier website.

“You can see in many cases that medical assisted dying is a treatment and like any other treatment, doctors have to use their judgment,” he said.

According to KGH’s official policy, requests for medical assisted death are “forwarded to an assessment team responsible for a process that includes screening and oversight.” The process, according to the policy, is done so that KGH meets all of the recommendations from the Supreme Court, as well as the professional bodies that govern clinicians.

More specifically, a patient can ask their doctor about the options of physician-assisted dying. Any doctor can be trained in how to do the procedure and it’s up to the doctor’s discretion whether a patient is a candidate or not. 

The rule at this time is that death must be in “the foreseeable future”. According to Hammond, what the foreseeable future is, is defined by individual doctors.  

If the patient fits this criteria and their doctor agrees, Hammond explained, the patient fills out a form that’s signed off on by their doctor. The request then goes to another doctor who also has to sign off — two doctors have to agree for the procedure to take place. 

The patient can choose if the procedure should happen at home or if they want it to be done at the hospital. Currently, according to legislation, doctors can either prescribe pills for the patients to take on their own or administer a lethal injection.

KGH’s implementation of medically assisted dying raises questions due to its merger with Catholic-based hospital Hotel Dieu announced in June. 

While the board and the financial aspects will merge, they will remain two separate locations and KGH will continue to perform doctor assisted dying, while Hotel Dieu will not, according to Dr. Tony Sanfilippo, cardiologist at KGH and associate dean of Queen’s undergraduate medical education. 

The Queen’s School of Medicine curriculum won’t be changing drastically, Sanfilippo said, as medically-assisted death is something doctors can choose to learn later in their specialties, without it needing to be explicitly taught in the first few years.

Additional information about doctors’ legal obligations in regards to assisted dying will be added to professionalism and ethics courses that are already part of the curriculum.

Even though medically assisted death has moved from theory to practice, controversy over the newly-legalized practice still exists among the Canadian public, and also among doctors themselves. Sanfilippo himself struggles with the concept of allowing people to choose to end their lives.

Since his specialty is cardiology, he won’t have to perform the procedure himself. It’s a choice for each physician, but he doesn’t condemn people who offer the procedure. 

“I have a lot of trouble saying ‘here is the point where we can’t do anything’ because there is always more medicine we can try,” he said. 

For Sanfilippo, the problem also comes when trying to make distinctions of who’s eligible.

“Suffering to one person isn’t the same to everyone,” Sanfilippo said. “Therefore, it’s hard to make a decision about who is making an informed decision about their lives and who thinks that they do not have other options when they possibly do.” 

He also talked about the concept of trust. Sanfilippo argues it’s possible patients might be frightened a doctor might jump to the conclusion that doctor assisted dying is the best option without trying to think of other options to help a suffering patient. 

“What that does to trust — I don’t know the answer to that but it’s something I worry about.”

For Allan Hammond, he sees it in a completely different way. 

“The reason I became a member of Dying with Dignity was because I liked the idea of being able to be independent. I have seen people who are struggling with debilitating conditions and being able to be independent in times like that is important.”

It’s been a long road for medically assisted death, but according to Hammond it’s far from over.

It started in September 1993, when the Supreme Court of Canada ruled against Sue Rodriguez who had ALS and wanted a physician to  assisted her dying.

In 2005, a Bloc Québécois MP, Francine Lalonde, introduced Bill C-407 which would allow a medical practitioner to aid someone in death if they had a terminal illness or were in severe physical pain — the bill didn’t pass. She would introduce it again in 2010 as Bill C-384, but it was defeated again. 

In June 2012, the British Columbia Supreme Court deemed Canada’s ban on doctor assisted dying unconstitutional because it discriminated against the physically disabled. 

In February 2015, 22 years after it first ruled against it, the Supreme Court unanimously voted to overturn the legal ban on doctor assisted dying. 

Finally, on June 17, 2016, the bill allowing doctor assisted dying became law.

In the overturning of the ban, the terms used for the procedure have also changed. 

Formally known as “doctor assisted suicide”, the term “doctor assisted dying” or “medically assisted dying” are common usage, for one, to avoid the negative connotations of the word “suicide”. Additionally, as medically assisted dying often occurs in the hospital and is performed by a doctor, it’s incorrect to term it suicide at all, according to Dying with Dignity Canada.

As of right now, the legislation passed requires the patient themselves to be able to consent, not leaving room for a next of kin or guarantor to make the call. 

“Our members and supporters are disappointed that the legislation doesn’t recognize any advance directive,” Hammond said. 

“If I had Parkinson’s for example, when I couldn’t recognize any of my family or friends, I would want to end my life, but I couldn’t anymore when I was at the stage where I was incompetent.” 

Dying with Dignity is working towards that allowance being made, as their next goal. 

The long-theoretical concept of doctor assisted death has moved to a currently-happening reality, but there remains issues to be worked out as hospitals adjust to the growing pains of a new practice. Questions like who can consent or a patient’s reasons for wanting to die may remain on the table. 

 For Dr. Sanfilippo, some of these questions of why a patient might choose death are unanswerable. 

“It can’t be legislated because it’s so personal.” 

Corrections

The merger between KGH and Hotel Dieu has been anounced but not yet completed. 

The Journal regrets the error.

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