The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
The Case For Legalizing Medically-Assisted
Dying in Canada
2014 Spring Family Medicine Conference
June 7, 2014
Derryck H. ...
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  1. 1. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) Derryck H. Smith, MD FRCP(C) Clinical Professor Emeritus Department of Psychiatry University of British Columbia Vancouver, British Columbia dhsmith@dhsmith.ca BC College of Family Physicians 2014 Spring Family Medicine Conference Vancouver, British Columbia Four Seasons Hotel June 7, 2014 Faculty: Dr. Derryck H. Smith  I have no financial or academic conflicts of interest to declare  I am a Board Member and Chair of the Physician Advisory Council for Dying with Dignity  I am not affiliated with any religious groups  I have been involved in the Gloria Taylor case as an expert witness  I have presented to the Liberal Senate Caucus on these issues.
  2. 2. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) • No Commercial Support Mitigation: The act of reducing the severity, seriousness or painfulness of something. • My goal is to mitigate the effects of a painful, meaningless death.
  3. 3. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  Why should we allow Medically-Assisted Dying in Canada?  What are the common arguments against Medically-Assisted Dying, and are they valid? For: 1. Individual autonomy 2. Relief from pain and suffering 3. An obligation to assist patients Against: 1. Intrinsic wrongness of killing( mostly religious based) 2. Integrity of the profession 3. Potential abuse of the vulnerable 4. Would detract from Palliative care There is no evidence to support 2,3 or 4 from jurisdictions where euthanasia in all its forms are legal.
  4. 4. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) • The Principle ethical principle in medicine and in western civilization is individual autonomy. • Competent patients who are in the terminal stages of dying should be able to have control over when they die and the interventions that are being used to keep them alive.
  5. 5. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) The wise man lives as long as he should, not as long as he can. He will always think in terms of quality, not quantity. Dying early or late is of not relevance, dying well or ill is. A prolonged life is not necessarily better, a prolonged death is necessarily worse.
  6. 6. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)
  7. 7. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  Sample was the City of Lethbridge and area  “Legalize Doctor-Assisted Suicide”  Agree 77.5% 2014 60.7% 2004 • Non religious 89.5% Agree • Highly religious* 53.2% Opposed * Attends church more than 2 – 3 times/month
  8. 8. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) Source: Forum Research Inc. December 2011  Sample 1,160 adults – December 13, 2011  67% favored physician assisted suicide of terminally ill patients  “I don’t know how I want to go, but I do know that I want to be the one who decides.” Wayne Sumner, Assisted Death: A Study in Ethics and Law  Polls routinely show that 60-80% of Canadians support the legalization of Physician-Assisted Dying  Support across all regions, genders, age groups, languages, income, and party affiliation  These numbers have remained steady since 1993  Highest support Quebec 79% , British Columbia 76% Environics Institute, October 2013
  9. 9. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) CMA Poll of 2125 members – Physician Assisted Suicide CMAJ , March 5, 2013 185(4) pp 357 Yes No Not Certain No Response If euthanasia was legal would you participate 20% 42% 23% 15% Participation in Physician Assisted Suicide 16% 44% 26% 15% Should assisted suicide be legal 24% 36% 59% had withheld life sustaining intervention following a request from a patient.
  10. 10. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) CMA Policy 2007 “Canadian physicians should not participate in euthanasia or assisted suicide.” CMAJ , March 5, 2013 185(4) pp 357  Timing and manner of death are arbitrary  Withdrawal of Life Support  Withholding of Life Support  Artificial feeding and hydration  Causation is subjective  Requests for assisted death are also related to terminal illness  Why should people have to wait for a fatal complication?  Potential for symptoms, trauma to family members
  11. 11. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) Frequently in my experience the debate is really about religious beliefs. My view: In modern pluralistic society public policy should not be driven by religious beliefs, but by maximizing the autonomy of the individual citizen.  Not physical symptoms ◦ 2/5 in importance  Loss of control  Dependence on others Ganzini. J Gen Intern Med 2007;23(2):154–7
  12. 12. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) • Death with Dignity Act passed 1993 • 2013, 71 people “hastened their death” • 0.2% of all deaths • 87% were in a hospice (versus 45% in other deaths) • 97% died at home • Number one reason “wanting control over their final days”
  13. 13. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  Assisted suicide ◦ Oregon (1998- 2012) ◦ Washington (2009-2012)  Does this describe a vulnerable group? Characteristic Washington Oregon Number 255 935 Age 85+ 15% 11.9% White 95.2% 97.6% High school graduate 94.1% 93.2% No health insurance 2.7% 1.7% End of Life concerns Loss of autonomy 90.6% 90.9% Inability to engage in enjoyable activities 88.6% 88.3% Burden on family 38.6% 36.1% Financial implications of treatment 4% 2.5% 1990 1995 2001 2005 Voluntary Euthanasia 1.7% 2.4% 2.6% 1.7% Assisted Suicide 0.2% 0.2% 0.2% 0.1% Life- terminating acts without explicit request (LAWER) 0.8% 0.7% 0.7% 0.4% Total 2.7% 3.3% 3.5% 2.2% End of Life Decision-Making in Canada: The Report by the Royal Society of Canada Expert Panel On End of Life Decision-Making 2011 Page 62 http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3265521/ The Dutch Experience Legal Termination of Life introduced 2001 This 73-page report concludes there is no evidence of a “”slippery slope”.
  14. 14. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  Need to be vigilant  Non-voluntary euthanasia  No law will stop people breaking the law  Assisted death/LAWER in countries where it is illegal  5.6% of deaths in NZ are assisted suicide or euthanasia  1/3 of Australian surgeons have given medications with the intention of causing death, often without a request Denmark Italy Sweden Doctor- assisted Dying 1.82% 0.1% 0.23% LAWER 0.67% 0.06% 0.23% Van der Heide et al. Lancet 2003;362:345-50. Mitchell and Owens. N Z Med J 2004;117:U934. Douglas et al. Med J Aust 2001;175:511-5. 2001 • 20% of deaths involve withholding treatment • 20% use of opioids • 2.4% active euthanasia • 0.2% physician assisted death • Public support for euthanasia - 90% • Doctors - 57% have performed euthanasia - 10% would never perform euthanasia There is no evidence that the availability of euthanasia undermines palliative care.
  15. 15. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C) http://www.telegraph.co.uk/health/healthnews/9631334/Doctors-to-investigate-use-of-controversial-Liverpool-Care-Pathway.html  Oregon MDs who opposed Physician-Assisted Death were 2x as likely to report a patient becoming upset or leaving their practice as a result of their position compared with physicians who supported Assisted Suicide  13% of MDs became more supportive of PAD with time, compared with only 7% who were less supportive Ganzini et al. JAMA 2001;285:2363-9.
  16. 16. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  What is “symptom control”?  Transient statistical improvement?  97% of patients in Oregon who received Assisted Death were enrolled in hospice care Oregon Death With Dignity Act, 2012 Annual Report http://www.healthoregon.org/dwd. Meyers FJ et al. JPSM 2004;28:548-556. http://www.assnat.qc.ca/en/actualites-salle-presse/nouvelle/Actualite-25939.html  Dying with Dignity – an exhaustive 175 page report on assisted dying  “unrealistic to believe that palliative care will be universally available in the near future (p 59)  In Europe “the legalization of euthanasia has boosted the development of palliative care”  The committee visited Belgium and Holland and were reassured that there was no evidence of abuse or a “slippery slope”
  17. 17. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  PC available to only 30% of Canadian population Carstairs, Raising the bar (2010)  Oregon – 0.2%  Holland – 2.2%*  Belgium – 3.8%* ◦ * lower than pre-legalization levels Oregon Death with Dignity Act 2011 Annual Report Van der Heide. N Engl J Med 2007;356:1957-65. Bilson et al. N Engl J Med 2009;361;1119-21.
  18. 18. The Case For Legalizing Medically-Assisted Dying in Canada 2014 Spring Family Medicine Conference June 7, 2014 Derryck H. Smith, MD FRCP (C)  Netherlands and Belgium  Growth in PC and hospice services  Oregon  Among highest rates of hospice referral, opioid prescription and EOL communication  Increased referral to hospice since legalization  Increase in MD self-education about PC practices  Clearer distinction between PC and PAD Quill T. NEJM 2007;356:1911-3. Ganzini et al. JAMA 2001;285:2363-9. 1. The majority of Canadians (and many dying physicians) want to be able to decide when to end their lives – PAD is the most reasonable option. Only 20% of Canadian doctors are in favor. 2. There is no evidence that a) Vulnerable citizens are being killed b) PAD undermines PC c) There is no huge increase in PAD over time In summary, there is “NO SLIPPERY SLOPE”. 3. Jurisdictions with PAD report general satisfaction from both physicians and patients.

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