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Can medical assistance in dying harm rural and remote palliative care in Canada?

20 March 2017

From an autonomy and informed consent perspective, unless there is available, easily accessible, comprehensive, robust end-of-life care, palliative care, to offer the option of assisted death impedes the exercise of self-determination and autonomy because you haven’t been given the option, and even if you have, it isn’t available to you in a robust way that can be actualized.Dr Thomas Foreman, Director, Champlain Centre for Health Care Ethics

Change has arrived in the Canadian health care system in the form of the Supreme Court of Canada’s unanimous decision to amend section 241(b) of the Criminal Code. Before this decision, it was illegal for physicians to hasten a patient’s death, known nationally as medical assistance in dying (MAID). The legal changes, however, made it a possibility fora competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.1

During the court proceedings, it was suggested that MAID can be justified based on current palliative care practices, but is this truly the case?One of the main arguments for the proposition that physician-assisted death can be an ethical practice is that physician-assisted death is ethically indistinguishable from conventionally ethical end-of-life practices such as withholding or withdrawing treatment or administering palliative sedation.2

The Canadian palliative care community has thus far expressed concerns about MAID, with most physicians stating they would not participate in the practice.3 The technical administration of MAID is unique in the traditional Canadian medical context, in that there is no existing specialist community to ensure appropriate training, standards of practice, competency, and expertise in troubleshooting (ie, the anticipation and management of adverse events). Physicians working in general practice rely heavily on guidelines and standards of care set out by subspecialty groups to manage various conditions. Canada’s rural and remote GPs manage a remarkably wide scope of practice, competently managing patient populations from birth to death. When rural and remote GPs decide to extend their scopes of practice to manage complex subacute or chronically ill patients, or acquire any skill that allows patients to remain in the community, it is assumed there are high-quality resources available to inform practice.

We argue that MAID presents a unique set of challenges to rural and remote physicians, particularly those who endeavour to provide high-quality palliative services to patients suffering from terminal illness. As most medically assisted deaths traditionally occur in the community, there is no doubt that this intervention will be requested of Canada’s rural and remote physicians. However, if these physicians are simultaneously committed to the provision of high-quality palliative care, should rural and remote GPs also be expected to provide MAID?

For the full article, visit Canadian Family Physician

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