Sit Down, Lean In

Virtual Hospice Executive Team Virtual Hospice Clinical Team Virtual Hospice National Advisory Committee

Canadian health care providers are experiencing a time of change and uncertainty, as the landscape of health services provision transforms with the introduction of what has most recently been termed Medical Assistance In Dying (MAID).

In the context of such an unsettling and polarizing issue, it can be helpful to remain grounded in one of the most foundational and fundamental imperatives of health care: to reduce the burden of suffering related to illness. This touchstone can guide our approach to supporting patients expressing a wish to pursue MAID, regardless of our personal or professional views on the issue.

We cannot address suffering if we do not engage with the person – not merely the patient – who is experiencing it. We must Sit Down, and Lean In.

Sitting Down can be figurative – it means we must pause, and connect. While such interactions may be more effective if we have an opportunity to literally sit down, care settings do not always allow for this. Nonetheless, when we encounter the expression of a wish to no longer be alive, this should be a “show-stopper”. We must pause. We must engage.

Leaning In is the process of exploring suffering. It does not mean “talking out of MAID”; rather it means an exploration of the life circumstances and illness experience underlying the desire to seek an earlier death than nature appears to have in store.

We all hold the credentials – the “admission ticket” – for engaging with those who are suffering: we are fellow human beings, who almost certainly have experienced loss and have been burdened by concerns of what the future might hold for us.  The ability to pause, to connect, to put a hand on the shoulder of someone in despair is not a complex clinical procedure – it is a fundamental human obligation.

The degree to which we Lean In will be influenced by our training, our clinical and life experience, and the context at hand such as environmental, cultural, and spiritual considerations. It may be that colleagues more familiar with the person and circumstances are better suited or skilled to address issues impacting quality of life. It may be that in-depth discussion must be deferred due to time constraints. Nonetheless, the very act of pausing, connecting – of Sitting Down – is an expression of acknowledgement and compassion that can be enormously therapeutic and meaningful.

Imagine the experience of someone being wheeled on a stretcher to receive radiation therapy for a malignancy, who in exasperation and despair says to an accompanying physician “I just wish you were taking me off to receive MAID”. There will be a profoundly different experience for the patient who is told “Well, that’s not something I’m familiar with or want to be involved in”, compared with if the physician stops the moving stretcher, touches the patient on the shoulder or the hand, and says “This all must be overwhelming for you – I’m so sorry to hear that you are feeling that way. When we get back to the ward, I’d like to talk more about this with you, if that’s OK”.

In this latter situation, there was a figurative Sitting Down, and enough Leaning In to convey a commitment. Not all physicians feel comfortable or capable to explore the social, cultural, or spiritual distress their patient may be experiencing. However, our interprofessional colleagues can be valuable supports in this. Such an engagement is “MAID-neutral”; the introduction of Medical Assistance in Dying has not changed our obligation to connect with those expressing suffering and despair.

Unfortunately, most of us lack confidence in our ability to speak about fears, sadness, anger, regrets, life’s meaning and purpose – that is, to explore the non-physical elements of distress. We live in a society that generally avoids such conversations, and the culture of medical education and practice does not prioritize such skills. As physicians, just as with most of society, we struggle with fluency in the language of suffering. This highlights a gap in medical education, at both undergraduate and postgraduate levels.

Rather than being a time-consuming distraction from the practice of “real medicine”, connecting with the whole person – not simply the physical manifestations and consequences of illness – is an efficient and effective path towards addressing the impact of illness on a patient. A sincere, compassionate connection can be profoundly impactful, even if it is simply a pause in conversation, a touch, a shared silence acknowledging the gravity of the situation and the validity of the concerns.

The landscape of health care provision in Canada is changing to include Medical Assistance in Dying. While physicians and other health care providers are divided on this complex and controversial topic, we must not lose sight of our shared obligation to strive to reduce suffering caused by illness. Regardless of our views on MAID, we have a fundamental obligation to engage with those who are suffering – to Sit Down, Lean In.

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