Not Euthanasia On Demand : The Beginning of the End

"We don't want these recipes made too easily available to everyone."
"It is clearly not euthanasia on demand. It is clearly not that."
"The whole process, from beginning to death] would probably take something around fifteen minutes. [Some of the drugs are] thick [they cannot be administered by a] bolus [or] high-speed injection."
"If the vein is clotting, probably they have to remove the needle and find another route of entry. [The cost of medications] is something surely less than $100."
"We are talking about the administration of drugs, so the effect is almost immediate. In an oral route, it can take hours to have the effect."
"We think there should be as minimum time as possible between when the act is begun and the effect occurs, to limit the effect on the patient, and on the family and friends."
"This is why it's so important before beginning the three steps that the physician checks, or validates a last time, the will of the patient."
"Nobody feels prepared. We are exploring a new continent. But we have to learn how to do this as best as possible. There is a beginning for everything."
Dr. Yves Robert, college secretary, College des medicine du Quebec

Phil Carpenter / MONTREAL GAZETTE    Dr. Yves Robert, right, secretary for Quebec's College of Physicians, speaks during a press conference with Dr. Charles Bernard, president-director general of the College, in Montreal.

The urgent need for doctors to be trained in best practices protocol has led to the formulation in Quebec of standardized kits to enable doctors to end the lives of patients who wish to depart this mortal coil. A collaboration between the Order of Pharmacists of Quebec and the Order of Nurses of Quebec, a formal guideline to aid doctors in this process has been developed and appears on a secure area of the Quebec College of Physicians' website.

The kit is to contain drugs to calm the nerves and drugs which will halt breathing. Included in the kit will be instructions to guide doctors undertaking the procedure in preparation for the province to usher in legalized assistance in dying for patients whose condition is deemed to make them eligible for euthanasia. The guide is carefully explicit, meant to aid doctors before, during and after administering euthanasia to eligible patients.

Set out in a step-by-step process is the type of drugs to be used, the correct dosage, the injection site and how to respond should complications arise. Quebec is set to become the first jurisdiction in Canada permitting competent adults whose life is suffused with intolerable suffering as their end of life approaches to seek "medical aid in dying". And that permission is to be introduced in December.

Quebec's Bill 52, the first of its kind in Canada, permits doctors the administration of lethal injections to patients suffering an incurable illness, in unbearable physical or psychological pain, who are considered to be mentally fit to make such a decision for themselves. The individual must be seen to be approaching the end of life, in an advanced state of irreversible decline.

The Supreme Court of Canada discarded the century-old Criminal Code prohibitions against euthanasia in February, opening up to euthanasia and physician-assisted suicide, while abstaining from defining "physician-assisted death".  A broad interpretation of physician-assisted suicide would have a physician write a prescription for an overdose that the patient would themselves administer to end their life.

The Quebec guidelines will appear as a template for the entire country. It has its origins in a formula that has been used in the Netherlands. The protocol that Quebec has adopted is for a three-phase approach via lethal injection. A benzodiazepine [type of sedative] would be injected to ameliorate anxiety and "help calm the patient". Then a barbiturate drug would be injected, inducing coma. The final step would be a neuromuscular block that causes "cardiorespiratory arrest", acting on the respiratory muscles.

Doctors are instructed to be alert for reactions; allergic reactions or vomiting, and to have a care not to lose access to the vein. The euthanasia packages, prepared by pharmacists, are to contain two complete treatments, should a backup be required. Unused drugs are to be returned to the pharmacy from whence they came.

To ensure that doctors in Quebec comply with the guidelines, an special commission on end-of-life care will monitor compliance. The Quebec college of physicians had looked elsewhere for guidance, consulting with the first doctor in Oregon who had prescribed a legal dose of life-ending drugs, discovering that "bad side effects" sometimes can arise. Oregon law prescribes drugs to be taken orally, not injected.

The early experience in Oregon has been that some patients have regurgitated the drugs, alternately in some instances "reawakened" hours, occasionally days, after swallowing the lethal drugs. The journey to death has, as a result, taken far longer, and caused more anguish in these instances than anticipated.

People who opt for euthanasia can put a halt to the processes at any time up to the last moment before consciousness is lost. Euthanasia could be performed in a hospital, in a palliative care hospice, or alternately, the individual's home, surrounded by family.

Assisted dying in Canada; urgent need for doctors to be trained

Planned Procedure

• A sedative to calm the patient;
• A drug to induce a deep coma;
• A drug to induce cardiorespiratory arrest (two sets of each drug to provide a backup in case of complications);
• Syringes;
• Needles in different calibre sizes;
• IV tubing;
• IV solutions.