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Physician-Assisted Suicide and Euthanasia: Introduction

By: Romayne Gallagher MD, CCFP

Many people have seen someone in pain and suffering. Physician-assisted suicide and euthanasia offer an immediate end to suffering, which makes them seem attractive options when life is coming to an end. From a distance this looks like a time of loss and suffering only. Yet many people who have helped care for a dying person whose symptoms are controlled have found that this can be an intense and rewarding experience.

It is important to discuss and debate these very fundamental issues, as the way we treat the most vulnerable among us says a lot about what our society values. It's useful to start by making sure we understand the terms of the debate.

See also: Physician-assisted Suicide and Euthanasia: The Issues

Euthanasia and physician-assisted suicide are deaths caused by a lethal drug prescribed by a physician. The drug causes the death, not the illness. In physician-assisted suicide, the patient takes the drug directly. In euthanasia, the physician administers the drug. Usually this is a barbiturate, given at a dosage that first causes sleepiness, and then leads to a coma and death.

In places where physician-assisted suicide is legal, there are processes to evaluate people who ask to end their life, to see if they are eligible for the programs. These processes usually involve in-depth talks between the patient and at least one physician. A second physician is often consulted as well. If the physician or physicians think the person meets the conditions of the program, then the physician prescribes a lethal dose of a drug.
 

Physician-assisted suicide

In physician-assisted suicide a doctor writes a prescription for a lethal dose of a drug that is intended to cause a patient's death. The patient is responsible for taking the prescription to a pharmacy to have it filled. Then the patient decides if or when to take the medication to end his or her life. The doctor does not administer the drug.

Here are two examples of people who asked for physician-assisted suicide.

 

Jean's story: Decreasing quality of life

Jean has advancing amyotrophic lateral sclerosis (ALS) or Lou Gehrig’s disease. It is a progressive disease that affects the nervous system and eventually decreases mobility, communication, swallowing and breathing, and independent functioning. Jean has been married for 45 years and her husband also has health problems. Jean is now having trouble walking because of leg weakness. Her arms are getting weaker also, and she now needs help with bathing, dressing and preparing meals. She gets daily support from community services and from her children, but she sees that this is causing her children hardship and stress. This weighs on her mind, because she knows that the burden on her children will only get heavier as she and her husband become even more dependent. The loss of independence and the knowledge that she is a source of difficulty and stress makes Jean feel her quality of life is decreasing and everything is over.

Jean talks at length with her family about this distress and how it leads her to seek physician-assisted suicide. The family is upset about this, but try hard to understand her reasons. Jean researches the process with her physician and submits a request to be considered for the program. After a thorough investigation, she is found to be eligible, and she gets a prescription for a lethal dose of drug. While she may still have had many more months to live, she decides to take the drug and dies.

Gary's story: Worries about unbearable pain

Gary has had advanced lung cancer for five months. He has had chemotherapy and radiation treatments for his disease. Despite treatments, Gary's cancer is progressing. He is losing weight and feeling weaker.  His cough has returned, he is having trouble sleeping at night, and he is increasingly short of breath. Gary still can shower and dress himself, and can get out of the house for short visits with his friends, but his pain is becoming more constant and intense, and he wonders how long he can continue these activities. His family helps by preparing meals, but Gary is worried that soon he will be completely dependent on them. He also feels his pain is becoming untreatable and is afraid his life will become  unbearable. Both these worries cause him great distress.

Gary tells his family he wants physician-assisted suicide. They are upset, but they support him. Gary investigates his government's process for physician-assisted suicide. He meets with two physicians who work with him to decide if he is eligible. After their decision, and a required waiting period, Gary is given a prescription for the drug. At the same time, Gary’s regular doctor refers him to palliative care and symptom management teams. They learn that the main reason Gary is asking to die is the intensity of his pain and shortness of breath, and his fear it will get worse. The symptom management team prescribes medication that helps relieve Gary’s pain. Gradually, Gary starts to move more easily and without becoming short of breath.  Gary meets regularly with a specialist who helps him talk about his fears and anxieties. Gary learns what he can control, and finds he can enjoy time with his family.  He decides not to take the medication prescribed for physician- assisted suicide for the moment. Gary keeps the prescription in case he needs it in the future. The symptom management team will work with Gary regularly to keep up his quality of life as long as possible.

  

Euthanasia

Euthanasia occurs when a doctor or other health professional administers a drug that ends a patient's life.  Voluntary euthanasia is when a patient requests the lethal drug. Involuntary euthanasia is when someone else decides the drug should be used to end the patient’s life. That person could be a family member, friend, substitute decision-maker or physician. If a person with dementia has no family, friend, or substitute decision maker to speak for them, then a physician may be the one who makes decisions on the patient's behalf.

The first story below is an example of voluntary euthanasia. The second illustrates involuntary euthanasia.
 

Dave's story:  Voluntary euthanasia when life feels not worth living

Dave is 32 and suffered a spinal cord injury in an accident eight months ago. He is a quadriplegic, which means his four limbs are paralyzed. He can breathe without the help of a ventilator (breathing machine) and he can move his shoulders. He has little movement in his hands and no movement in his legs. Since his accident he has learned to use a motorized wheelchair and can go out on his own. He can speak and hear normally and can use a computer directed by head movement. At the time of his accident, Dave was estranged from his family and has not let them know about his condition. He is divorced and has no children. His work and his sports friends were his life. Dave’s friends have been very supportive and he has visitors every day. Despite his recovery, Dave still feels life is not worth living. He can't play sports—something he did every day before his accident—and he needs help with dressing, bathing and toileting.

Dave lives in an area where physician-assisted suicide and euthanasia are legal. He cannot take lethal medication himself, so he investigates the process for being considered for euthanasia. After a careful investigation, Dave is considered eligible. Several weeks later a doctor administers the lethal dose of a drug and Dave dies about 40 minutes after receiving it. He likely had many years to live despite the complications from his quadriplegia.

Louise's story: Involuntary euthanasia for someone incapable of making medical decisions

Involuntary euthanasia for someone incapable of making medical decisions
Louise has advanced dementia. She can no longer understand the pros and cons of medical treatments. She is considered incapable of making medical decisions for herself. She has two daughters who know her well and are active in her life. They are her substitute decision makers. When Louise was in the early stages of dementia, she told her daughters she felt she would not have the quality of life she needed if she had to live in a nursing home and could not make her own decisions. Louise asked her daughters to respect her desire not to live like that and to help "put me out of my misery" if that situation came up.

Louise is being cared for in her apartment in a seniors’ complex. She needs help to dress herself and can only walk a few steps. She eats well if someone helps feed her, and she seems to enjoy music therapy sessions and visits. Her daughters talk often about what to do for their mother now that she needs more care and a transfer to the nursing home side of the complex is likely. Louise’s health care providers tell  her daughters that studies show people with dementia have a better quality of life than their families think. The daughters agonize over what's best for their mother and her gradual decline, and wonder how to balance possible quality of life with the wishes she expressed in the early stages of dementia. After several month's of watching Louise decline, the daughters ask that she be considered for euthanasia. After an evaluation process, which considers Louise's earlier wishes, she is judged to be a candidate for involuntary euthanasia. A doctor administers a lethal dose of medication to Louise with her daughters by her side. There is no way of knowing how long Louise may have lived without euthanasia.


Every person's story is different, and each has to be considered carefully. Society's role is to ensure all options are considered for those final days, and that decisions are carefully made.


Physician-assisted suicide and euthanasia in Canada

Physician assisted suicide and euthanasia in Canada has been termed medical assistance in dying (MAID). Medical assistance in dying in Canada applies only to people who are fully able to make an informed decision, who have a serious illness, are in an advanced state of decline, are suffering unbearably from their illness, and are at a point where their natural death has become reasonably foreseeable.

A Supreme Court of Canada decision has made medical assistance in dying legal in Canada starting in February 2016.  Bill C-14, legislation on medical assistance in dying in Canada, received royal assent on June 17, 2016.

Decision-making about MAID and provision of medical assistance in dying lies outside the palliative care focus of CVH. 
Information about medical assistance in dying can be found on the Government of Canada’s website. 

The Canadian Virtual Hospice (CVH) provides information and support to manage illness through a palliative approach to care. This website has many valuable articles and videos about serious illness as well as grief and loss. Please search our website for information and supportive ways to cope.

Content Reviewed August 31, 2016