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The doctor who took on death

23 August 2017

In an agonizing personal and professional decision, Dr. Sandy Buchman opted to help patients with their final wish. He hasn’t looked back.

The family is waiting at the open door of their apartment before Dr. Sandy Buchman is halfway down the hall. When he steps inside, they tell him things have declined sharply in recent days. Buchman asks to see his patient, John, before they talk further—he knows he’ll be able tell a lot just by looking at the man. John’s wife, Margaret, and their three adult daughters (names have been changed) lead Buchman into a small bedroom, where a cold, wet early-May morning is sliding past a broad swath of windows.

John, who is 90 and has metastatic prostate cancer, lies unresponsive in a hospital bed in the middle of the room. His face is pinched rather than slackened in repose. “He’s in pain now,” Buchman says softly. One of John’s daughters remarks that their names are the only thing he’s been able to say in recent days. Buchman asks her to speak to her father; she does and receives a low moan in response.

The family has a host of questions about the changes they’ve noticed. Buchman explains that the purple, cool spots on John’s feet and legs are called “mottling,” then he addresses the long, uneven pauses in John’s breathing. “This is called apnea,” he explains. “It’s a late sign that someone is actively dying.” His tone is gentle but straightforward. One of John’s daughters begins to weep: “It’s so fast.” By this point in the dying process, families generally grasp the reality, but it’s difficult to hear their fears confirmed. “I think it’s a matter of hours,” Buchman tells them. “I wouldn’t be surprised if he passes today.”

With John’s family clustered around his bed, Buchman discusses controlling his pain using morphine drops that will absorb into his system even though he can no longer swallow, and he recommends using moistened swabs on his mouth to keep him comfortable. “What do you have for wives?” Margaret asks with a wobbly laugh. “Well, we have lots of TLC,” Buchman says, placing a hand on her shoulder. Before they leave the room, she proudly shows the doctor their wedding portrait and family snapshots arrayed on the windowsill.

Later, at the dining room table, Buchman walks the family through how to care for John through his final hours. “When he passes, you don’t call 911, you call me,” he says.

Buchman has been helping dying patients—which to him means helping them live as well as possible until death overtakes them—and their families for three decades as a palliative care doctor. But there’s now a new and profoundly difficult issue on the frontlines of death and dying: patients who want their doctors to actively help them die on their own terms and timeline. The legalization of assisted death in Canada—commonly called medical assistance in dying, or MAID—a year ago has prompted a sort of existential reckoning among doctors across Canada, but nowhere so dramatically as within the specialty of palliative care.

Individual palliative care physicians, including Buchman, 62, have had to sift through their deepest emotions, values, tenets of faith and the very reasons they chose this field of medicine in order to decide whether they will help their patients die. Palliative care specialists seemed to their colleagues like the obvious people to handle the highly fraught issue and practice of assisted dying. But the mission and philosophy of palliative care is, for many who do this work, uncomfortably at odds with helping people to die. The World Health Organization definition, which guides many hospices, physicians and nursing staff, holds that palliative care “provides relief from pain and other distressing symptoms,” “affirms life and regards dying as a normal process” and, crucially, “intends neither to hasten or postpone death.”

It took Buchman more than two years to puzzle through all of this before he ultimately decided that helping eligible patients who wanted and needed to end their lives was an extension of what he’s been doing all along: relieving suffering. And the first patient he helped to die was in many ways the ideal partner with whom to venture into this unknown territory: a fellow physician who knew too well the fate of his disease and was determined to take control of his own ending.

“I have a lot of colleagues I highly, highly respect in palliative care—I even worry about it now—and I just know how strongly opposed they are to medical assistance in dying being legal,” Buchman says. “I have total respect for their beliefs and values, and I think they’re good people. Still somewhere in me is the fear that they’ll think I’m not a good palliative care physician.”

He harbours the same worry you hear again and again from palliative care specialists who have landed on either side of this charged decision, and at every point in between: they’re afraid to be judged.

By mid-morning, when Buchman leaves John’s apartment building in east Toronto and tosses his red-and-black backpack into his SUV, he’s been working for hours. His pager starts going off at 7 a.m., and the team at Sinai Health System’s Temmy Latner Centre for Palliative Care (TLCPC), where Buchman has worked since 2005, begins each day with a “huddle” by conference call to discuss what happened overnight and how their patients are doing. TLCPC is one of the largest palliative care programs in Canada, and unusual for operating largely through home visits.

Perhaps because his car is his mobile office, Buchman drives with the pitiless confidence of a cab driver, navigating from one patient’s home to another with his phone’s GPS yelling directions.

Palliative care came to Canada in the 1970s, when cancer treatment was rapidly expanding. But those who work in the field say it’s still poorly understood or inaccessible for too many people who need it. “There have been so many misunderstandings about palliative care over the last 50 years, where people have thought, ‘Oh, they go in, they give them morphine, they hold their hand and they die quickly,’ ” says David Henderson, medical director of the Colchester East Hants Palliative Care Program in Truro, N.S., and president of the Canadian Society for Palliative Care Physicians (CSPCP). “For 50 years, we’ve been trying to help people understand that palliative care doesn’t hasten death and that it can really promote improved quality of living.”

As a new doctor, Buchman had just opened a family practice in Mississauga, Ont., when, in 1984, a patient in his 40s came in suffering from a mysterious pneumonia. There was no test for HIV/AIDS at the time and little understanding of the illness. Buchman offered to refer the man to a specialty clinic opening at a Toronto hospital. “He said to me, ‘Do they know anything more than you do?’ I remember those words. And I said, ‘I don’t think so,’ ” Buchman recalls. “And he said to me, ‘I’m too sick and it’s too far. Will you look after me?’ I said, ‘Of course I’ll look after you.’ ”

That’s how Buchman launched into learning about AIDS and palliative care at once. It hadn’t been covered in medical school; all Buchman knew was what he’d learned from reading Elisabeth Kübler-Ross’s seminal 1969 book On Death and Dying. He set about looking for resources to study, attending any information sessions he could find and apprenticing himself to a colleague.

To Buchman, palliative care is “total care” that addresses “total suffering.” That encompasses physical symptoms such as pain, nausea, loss of appetite and fatigue; the psychological and emotional toll of a life-limiting illness; the existential or spiritual suffering of people facing limited remaining days; and support for their families. It means letting a patient define what makes their life worthwhile and enjoyable—be it painting, being able to communicate with loved ones or simply enjoying a bowl of ice cream—and what would rob them of dignity or their sense of self, like having someone look after their bodily functions or being unable to recognize people they know. “It’s about providing a good death, if I can put it that way—about optimizing the dying process for a patient and their family,” Buchman says. “So in a way, it’s always about living.”

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