End-of-Life Health Costs

"Neither patients nor physicians should consider costs when making the very personal decision to request, or provide, this intervention."
"As death approaches, health care costs increase dramatically in the final months. Patients who choose medical assistance in dying may forgo this resource-intensive period."
"Providing medical assistance in dying in Canada should not result in any excess financial burden to the health care system and could result in substantial savings."
Report, University of Calgary research

"There was no agenda to this cost analysis. We're definitely not suggesting that medical assistance in dying be chosen over any other way of dying."
"We're just trying to describe the reality that may exist in Canada [under a new law]."
Dr. Aaron Trachtenberg, resident, internal medicine, study co-author

"[The difference between one and four percent of all deaths] represents a grey zone of about 8,000 Canadians. The very notion of costing end-of-life care and estimated savings with medical aid in dying is a bitter ethical quandary for some."
"We should quickly move past counting dollars saved from medical aid in dying, and count instead the days of unbearable suffering that result from missed opportunities to provide palliative care."
Dr. Peter Tanuseputro, Bruyere Research Institute

New research suggest medically assisted dying could result in substantial savings. But the study's author says costs should not be considered when individual patients consider the option. (Chris Kreussling)

Indeed, the conclusion reached by the research team out of the University of Calgary, published in the Canadian Medical Association Journal of the economic efficacy in savings up to $139-million annually in aiding dying patients to kill themselves before the natural process of dying completes its journey -- as a remedy to high health costs associated with the last living days of people moving toward the final days, weeks, months of their lives -- does leave an acrid taste in one's sensibilities.

The analysis, based on those Canadians expected by the system to choose an assisted death, and the amount of time a person's end-of-life might be quickened, the costs of care immediately preceding death based on emergency department trips, dialysis treatment and hospital admissions led to the calculation that the cost of offering doctor-hastened death would lead to a gross medical-health savings that would more than balance the cost of doctor-aided death as opposed to continued health care until death.

With the experience of the Netherlands and Belgium as a guide, the researchers were able to estimate medical assistance in dying would play a role in one to four percent of all deaths in Canada, resulting in approximately 10,722 deaths annually. Of those deaths, an estimated eighty percent would be struggling with cancer; fifty percent would be between 50 to 80 years of age, and sixty percent would have had their lives cut short by an average of one month. Based on physician fees in Ontario the calculation was that direct total cost of doctor-hastened death would range from $269 to $756.

Medical assistance in dying (MAID) in practise, has the potential to reduce annual health spending by $35-million to $139-million. For 2016, Canada was projected to spend $228-billion on health care. According to one Ontario study, the average person is responsible for generating $14,000 in health-care costs through the last thirty days of their life, inclusive of receiving intensive treatment which, in the end, serves frequently to temporarily delay otherwise-imminent death.

"Canadians die in hospitals more often than, say, our counterparts in America or Europe and … we have a lack of palliative care services even though we are trying to improve that. And therefore people end up spending their final days in the hospital", explained Dr. Trachtenberg further. "Hospital-based care costs the health care system more than a comprehensive palliative care system where we could help people achieve their goal of dying at home."

John Moore / Getty Images   Hospice volunteers caress the hands of terminally ill patient

At the Core of Assisted Death in Canada

"The issue of conscientious objection is huge and it's related to the issue ... of how physicians feel about this [becoming medically involved as doctors in assisted death]."
"Some of them are obviously quite uncomfortable about referring as well."
Dr. Cindy Forbes, president, Canadian Medical Association

"In the early days of this [Alberta's Medical Aid in Dying program], we got hate mail. I've been publicly identified early on as doing this work [assisted suicide]. We have an email address, and I've been told I'm a murderer and other things."
"We could become targets, and we don't want that to happen. [The list of pharmacists is also] very tightly held."
Dr. James Silvius, medical director, Medical Aid in Dying, Alberta

"We are aware that physicians are concerned about the potential of unwanted interference [public protests, harassment, violence]."
"That probably dates back to the abortion struggles."
Dr. Douglas Bell, associate executive director, Canadian Medical Protective Association

"We do recognize that not everyone is comfortable with medical assistance in dying and it is for that reason that we will not be disclosing which primary-care providers are willing to be part of this new service."
Lauren Kelly, manager, physician services, Prince Edward Island

"My sense is not so much a polarization in terms of stigma where people are saying 'You're a euthanizer', and 'You're a fundamentalist'. I think there is still some basic confusion about some elements in the law and regulations. You'd think they'd be perfectly clear, but they're not."
Dr. Eugene Bereza, director, Centre for Applied Ethics, McGill University Health Centre

Minister of Health Jane Philpott speaks to reporters after delivering a speech at the HealthCareCAN and the Canadian College of Health Leaders' National Health Leadership Conference in Ottawa on June 6, 2016.  (Sean Kilpatrick/THE CANADIAN PRESS)

It might seem reasonable to most people to think that a critical medical service loathed by many and passionately longed for by many others, mandated as a human right in this country by the Supreme Court of Canada, with guidelines issued by the Government of Canada, would be available in all provinces with similar conditions applying everywhere. But the truth is, uniformity eludes. And the truth is that many health practitioners look upon the very idea of helping a patient die when their profession is geared toward sustaining life, are hugely unwilling to be involved in assisted death.

In Montreal, McGill hospital made it clear that it would not be offering that service to patients. Their doctors are appalled at the very notion that it would be expected of them to guide patients to their death rather than offer palliative care when their condition has become so dire that there is no hope to prolong life. This is what they consider to be death with dignity, not ushering people in pain and misery toward their own funerals.

Yet the Province of Quebec was the first in the country to begin the process of laying out guidelines and expecting medical practitioners to follow them. The result has been that in Quebec so far 166 such procedures have been completed to the end of June, as compared to 9 in Alberta, 18 in Ontario and 5 in Manitoba. Of the 254 requests made Canada-wide for assisted suicide, 166 of those took place in one province alone; the province that considers itself the most 'progressive' of all.

Ideally, Health Canada would prefer to see all provinces put together care-coordination services even though federal regulations do not require that be the case. Health officials visualize that terminally ill patients and their families will be faced with the need to themselves look about to find a physician who might be agreeable to taking part in the procedure they hope will follow. Surveys undertaken by the Canadian Medical Association reveal that sixty-one percent of doctors identified themselves as conscientious objects to assisted death.

On Prince Edward Island health authorities are undertaking a survey of physicians to determine whether they would be willing to discuss assisted dying only with their patients, or whether they might extend the service to any patient on request. The federal law was controversially passed on June 17 and since then Alberta, Ontario, Manitoba, New Brunswick and Northwest Territories still lack guidelines for a centralized service. Saskatchewan and PEI are in the process of compiling a list of doctors willing to administer the deadly drug cocktail when a terminally ill patient who meets the requirements for assent, asks for the service.

Quebec has had a head-start since doctor-assisted death has been legal in that province since December. Doctors there who refuse to take part in the procedure or to refer patients to another physician face censure. Neither Quebec nor Nova Scotia have a central referral service through their health ministries. And doctors generally fear to advertise that they will aid in the procedure and risk being identified as a provider of euthanasia.

Thus far, Alberta is one of the first to set up their central service to maintain doctor and pharmacist lists of those who can be relied upon to help patients take their lives. That list of doctors is held as a document not to be publicly disclosed which only the medical director in each of Alberta's five health zones may access. The issues of medical ethics and physician protection is an emotionally fraught one. Before the federal law on assisted death was passed physicians kept their identities confidential.

The McGill University Health Centre's reluctance to become involved, in support of their medical professionals who object to providing the service, has agreed to alter some of its policies in response to criticism generally, and pressure from government health agencies. The Quebec Health Minister's characterization of the policies as a "childish" reaction elicited the response from the head of the hospital's palliative care unit, Dr. Manuel Borod, that their figures for assisted dying were low owing to their high value of palliative care, minimizing patient suffering.

"The real question you should be asking", said Dr. Borod, is: "why are so many cases of medical aid in dying taking place elsewhere and so few at the MIHC?" It's a fair question in view of the province's oversight body having notified doctors that on occasion some have performed the procedure on patients not in a terminal phase as set out in provincial law. "Some people think aid-in-dying can be 12 months or more (before death is expected) whereas others think it means weeks -- maybe a month or two. That can make a big difference", observed Dr. Eugene Bereza, director of McGill's Centre for Applied Ethics.

And, added Dr Cathy Ferrier, a McGill hospital geriatrics division physician, and president of Physicians' Alliance Against Euthanasia: "I know of people who were trying to start a new palliative-care centre that they'd been working on for several years and were told this year that they would not get public funding. Is that because they don't intend to euthanize patients? I don't know, but it could be."

Objecting Conscientiously

"The whole idea of basically sending them [patients in morbid end-of-life decline] to their death, I abhor."
"[Families already have asked] what about this euthanasia legislation [in Canada]? They would say, 'what do you think about it? And, if mom starts having a lot of suffering, can we count on you to be the provider?"
"I loved my patients. I feel very strongly people are a precious commodity. I thought, 'I don't want to be faced with this'."
Dr. Nancy Naylor, family physician, Strathroy, Ontario

"The prohibition against assisting someone to commit suicide is millennia old. You don't just strike out those conscientious beliefs with the stroke of a pen after they've existed for hundreds and hundreds of years."
Jay Cameron, lawyer, Justice Centre for Constitutional Freedoms

"The idea that doctors are somehow special and that their private views matter more than doing their jobs is ridiculous. [ The Hippocratic oath is] a very old document written by members of a Greek sect, with its own peculiar history [with no legitimate bearing on the practise of modern medicine. It isn't fit for today's purpose, and even if it was, those deploying it as a means to avoid providing particular professional services pick and choose only those bits they agree with and ignore the rest."
"It seems weird that  you would choose to become a professional in a particular discipline voluntarily, you know the scope of practice can be changed by society. And then you turn around and tell people in that society that enabled you to do all these things, 'Stuff you, because, quite frankly, my private beliefs are so much more important'."
Udo Schuklenk, bioethicist, Queen's University

Dr. Schuklenk has no sympathy whatever with the private consciences of physicians and other health-providers who will be called upon to participate in Canada's new assisted suicide laws guaranteeing the escape of death to people whose health has failed catastrophically leaving them with no future other than a continued steep descent into the finality of death. There are many such health providers who wince in pain at the very prospect of this law coming into full regulatory force.

These physicians and other health practitioners who will be expected to use their medical expertise and the trust that patients hold them in, to usher patients with hopeless medical conditions toward death on request feel instinctively that this will transform them from healers to killers, and they refuse to either condone or participate in the new protocol of euthanasia. Even that part of the protocol that would permit them to step away from active participation by referring to another doctor who has no such qualms horrifies them.

The manner in which such protocols have spiralled into the kind of use that has granted legally-assisted death to people who simply are sick of life, people who refuse to compromise with reduced quality of life, including accepting the death wishes of children whose lives are painful torments rather than proffer to them, as needy patients, all the survivability that medical science can offer with palliative care, stuns these objectors.

Dr. Schuklenk and a colleague Ricardo Smalling have written a paper published in the Journal of Medical Ethics that no regulated and lawful health system should permit any doctors to choose to be exempt from taking professional part in assisted suicide, that their pleas for accommodation should be rejected. "In more rural communities you could easily have 100 percent conscientious objectors", he pointed out.

On the other hand, the Canadian Medical Association feels that his argument is strictly in the realm of pure theory "Until I hear of an example that, in such-and-such a place there are ten doctors and none of them want to participate, then I would say we just don't have evidence that will happen", was the tart rejoinder by Dr. Jeff Blackmer, head of medical professionalism at the CMA, rejecting that defense of Dr. Schuklenk's contention.

The perspective of Dr. Brad Burke is that voluntary euthanasia and assisted suicide had not even remotely entered the conversation when he began medical school in 991. "No one ever thought this could happen." This Windsor Ontario physician practices medicine and rehabilitation, treating people suffering the aftermath of severe strokes, spinal cord injuries and head trauma. The very health demographic he feels representing those who could very well "ask me to kill them, or refer to someone who would."

Tyler Brownbridge / Windsor Star    Dr. Brad Burke argues assisted suicide and voluntary euthanasia were nowhere on the horizon when he entered medical school in 1991. 'No one ever thought this would happen.'

"I believe that everyone is created in the image of God. I have no problem trying to do my best to care for patients and to be compassionate. I just don't feel killing them is compassionate", he added. He renewed his medical licence in Michigan this year, where assisted suicide is illegal. As for Dr. Naylor, a practising physician for the last 37 years, with this new law coming into effect, she feels she has no option but to hang her shingle up high on a shelf to gather the dust of regret.

Assisted Dying

"The tough cases fall in the grey zones. People's lives don't fit neatly into boxes and checklists."
"It's only reasonable to expect things don't work perfectly smoothly on day one. There's no way of knowing at this point how many patients requested [assisted death] and were blocked."
"End of life is available. If you're suffering and you're dying; just ask for it, you'll get it [the feared and incorrect message coming through to the public]."
Dr. Eugene Bereza, director, centre for applied ethics, McGill University Health Centre, Montreal

"Yes, the death of a family member is traumatic. A death of a patient under your care is also traumatic. But what about if you actually went to the extent to [not only] alleviate pain, but terminate the life?"
"A police officer involved in a shooting, they get support. What about doctors that are getting involved in these types of discussions, that actually perform the act. It's going smoothly for the moment [assisted death practised in Montreal under the law permitting such medical intervention] but the aftermath is what we need to start to care for."
"We're hearing it changes the relationship; it changes how you interact with the care team after making such a decision. There's that effect that I think we need to start to manage."
"The hard part is what comes after."
Normand Laberge, executive director, Quebec Medical Association

MPs will have a free vote on new legislation doctor-assisted suicide that was tabled today. (Shaun Best/Reuters)

Conventionally and historically the role of the medical profession has always been to assist people to live. When health crises arise, this is the profession to which we turn for diagnosis, advice, prescription, support and encouragement. "Do no harm" is what the profession has embraced, and certainly not "when all else fails, offer death". In the best of all possible worlds there would be no acute medical crises to be handled; alternately, once such crises arise the warmth and security of palliative care would ease the suffering toward eventual death.

Canada, however, following directly in the lead of the Province of Quebec, has decided, because the Supreme Court of Canada saw fit to strike down prohibitions against assisted suicide citing the law prohibiting assisted death as violating Canadians' Charter rights, has now passed the requisite legal hurdles to make it possible for some adults under some circumstances to request and to receive assistance in seeking death. Such physician-assisted death is to be restricted to mentally competent adults suffering from serious and incurable illness, disease or disability.

The bill, tabled on April 14 in Parliament, sets out protective safeguards to ensure that vulnerable Canadians are not absorbed into a process they have no wish to be part of. A parliamentary committee that had been struck to consider and issue recommended guidelines included extension of the right to die to "mature minors" as well as the mentally ill, and extending the potential for inclusion for patients with degenerative disorders to issue advance consent. Not all of the recommendations were accepted.


The bill also:

• Protects people from being encouraged to die in "moments of weakness."
• Includes a mandatory 15-day "reflection period" so people don't make rash decision after a diagnosis.
• Re-affirms goals on suicide prevention and encourage a "consistent approach" across Canada.
• Allows doctors and nurse practitioners to provide assistance without risk of criminal charges.

But what Dr. Laberge is concerned with, now that Quebec is four months into its euthanasia assistance to eligible patients program, is the fallout effect of potential trauma on assisting medical practitioners. A process that was once far from anyone's imagination has now become legal in Canada. Since assisted death became legal in Quebec in December a few unexpected situations in dealing with the issue have already arisen. One doctor tried to block a terminally ill cancer patient's access in reflection of his personal moral opposition to assisted death.

Raising the larger issue of patients erroneously believing that "Euthanasia on demand", has become a legal end-of-life process in Canada is yet another complication that must be clarified. Another emerging challenge is how to treat people whose situation "almost fits" the criteria for acceptance, but who are denied on the basis that they are missing one of the key criteria. A man from Sherbrooke met all requirements other than that his death was not imminent. He  had lost use of his legs and stopped eating in order to qualify for an assisted death.

"That must have been three or four weeks of hell, for everybody involved", noted Dr. Laberge. Who feels it is critical that doctors need more guidance so that those who are willing to take part in assisted death protocols that act with a level of confidence, and those who are not prepared to take part in assisted death as well, are helped "through the ethical discussions you're going to have with yourself".

Assisted Death as Treatment

"For all my love of life, I do not fear death. In the early stages of the disease, I fought back hard as long as there was hope for recovery. Only when the pain became too much to bear and it became evident that there was no positive outcome did I turn my focus to managing my own death. I have a strong wish to die with dignity at the time of my choosing."
"I have become a skeleton of the man I was. My suffering is intolerable and unbearable."
Toronto man, 80, father, grandfather

Fred Dufour/AFP/Getty Images/File   Physician-assisted death should be viewed simply as a “treatment for an underlying illness,” lawyer Andrew Faith argued in a case that offers a poignant glimpse at the kind of suffering that can drive someone to plead for a premature end

 

Reduced to a shadow of the man he once was, the man, recognizing what he speaks of as a "wonderful" existence since he arrived in Canada, speaks of the agony of the blood cancer that has now spread into his spine, and that the painkillers given him are not capable of reducing his pain. And nor can he perform any of the most basic of all self-help actions of life without assistance, let alone have control of his bodily functions.

Reduced to a shell, housing an active brain suffused with memories, he knows he has not been given very long to live, a matter of mere months, but his suffering is too intense to bid him to bide his time. He has suffered enough, and at this juncture he feels it is in his best interest and the interests of those who surround and care for him, that his exit from life be accelerated to free him from the physical torment he now experiences.

He has filed an affidavit in a Toronto court supporting his request. He is entirely lucid and more than capable of making a choice of his own volition. By order of a Superior Court justice media has been banned from publishing the man's identity or that of his family, nor of his health-care team. That information has been redacted from the documents presented at court.

His decision to preempt nature's plans for his life-ending was paved by the year-ago ruling of the Supreme Court of Canada, sweeping aside the Criminal Code ban on assisted suicide, for its perceived unconstitutionality. The government has yet to officially change the law, but that process has begun and is due in June; too late for this man and any others in a like position. By appealing to the court he is able to obtain permission to proceed.

When he was diagnosed with aggressive b-cell lymphoma in July of 2012 he underwent chemotherapy. However, its severe side-effects led to hospital admissions, convincing him to put a stop to the treatment. A year later the disease's symptoms became far more aggressive, leading to palliative chemotherapy. By the fall of 2015 a dramatic increase of symptoms caused him severe pain, fatigue, nausea and "profound" weakness.

By the turn of the year in 2016 his decision was made, to choose assisted death. His daughter speaks of her father as an "inherently happy man". His Toronto-based hematologist has stated that his patient whom he has treated since 2012 has no more than three months of life left to him, and that he is himself willing to assist in the administration of the fatal injection.

The doctor has no wish to have his name made public, and that extends to his involvement in this sad case. "Nor do I intend to make providing physician-assisted death a significant part of my practice."
The man's lawyer asked the court not only to approve the aided death, but to make certain a coroner's inquest not result; that the man's death be certified that it is the cancer that was the cause of death, and not a lethal injection of barbiturates.

Lawyer Andrew Faith rendered his view that physician assisted death be considered a "treatment for an underlying illness", in which case, lymphoma should logically be recognized as the cause of death, and not that the treatment be listed as its cause.