By CHPCA, March 23, 2015
Canadians are at the forefront of great change regarding how we will conceptualize and implement new legislation to care for our dying citizens. With that in mind, this summary will examine how two other jurisdictions, Belgium and Oregon, with similar legislation enacted previously, have addressed these issues within the framework of and connection with palliative care services. The rationale for looking at these particular jurisdictions is based on Belgium’s well-developed palliative programs and the relatively high confidence level in their health institutions. Oregon physician-assisted death program is examined, as it is likely a similar model to what may develop in Canada.
Historically, palliative care and physician-assisted dying were viewed as fundamentally opposing practices. Dame Cicely Saunders, Dr. Kathleen Foley, and Dr. Balfour Mount, all well recognized leaders in palliative medicine, indicated disapproval of physician-assisted dying. As an increasing number of jurisdictions worldwide accept physician-assisted death as an option for those with life-limiting illness, is there evidence that the two seemingly antagonistic causes In Belgium, euthanasia was legalized in 2002. It has been suggested that a well developed palliative care system may have enabled the legalization of physician-assisted dying (Bernheim et al., 2008).
Prior to the 2002 passing of Belgium law regulating physician-assisted dying, the federal budget doubled its allotment for palliative care based on the undisputed merits of palliative care and the widely held belief that physician-assisted dying would be unethical if carried out as a result of a lack of available and appropriate palliative care (Bernheim et al., 2014). Concerns that the new legislation could stunt the development of palliative care or diminish a culture of compassionate or competent care were unfounded.
Bernheim et al. (2014) report, that in Belgium, palliative care expenditure grew steadily in the 5 years following legal regulation, by a yearly average of 10%. There is no indication that Belgium lagged behind countries without euthanasia in the development of palliative care.
Initiators of palliative care in Belgium advocated strongly that access to proper palliative care was an essential precondition for the acceptability of euthanasia and that the two ideally should develop together.
Currently there is a high level of community support, including the public, palliative care workers, other health professionals, and legislators, for the Belgian model of integral end-of-life care. The model suggests euthanasia is an available option at the end of a palliative care spectrum of services (Bernheim et al., 2014). Under constant surveillance, the Belgian model continues to evolve in its practice and procedures.
Chambaere (2015) reported that the rate of euthanasia in Belgium increased significantly between 2007 and 2013, from 1.9 to 4.6% of deaths. Decision-making in euthanasia more often included both oral and written requests from patient and physician in 2013 as compared to 2007, which indicate a stricter adherence to both requirements of the euthanasia law. Palliative care services were involved in 73.7% of cases in 2013.
The Oregon Death with Dignity Act passed in 1994 and enacted in 1997 legalizing physician-assisted suicide for competent and terminally ill Oregonians. Physicians were given the ability to prescribe a lethal dose of medication to qualifying adults, for the purpose of selfadministration. Initial concerns included that legalized physician- assisted suicide would reduce efforts aimed at ameliorating care for dying patients. Conversely, studies demonstrate that care for terminal patients has improved in Oregon since the passage of the Death with Dignity Act (Ganzini et al., 2001). Recently, the American Academy of Hospice and Palliative Medicine changed its terminology, replacing “suicide” with a more neutralized and descriptive “physician-assisted death.” Legalization in Oregon has resulted in a fairly stable practice of physician-assisted death wherein it accounts for 1 in every 1000 deaths (Quill, 2007). Currently, nurses are prohibited from participating in physician-assisted death by the Code of Ethics for Reportedly, discussions about physician-assisted death are happening more frequently with 1 in 50 dying Oregonians discussing end-of-life options with their doctor (Quill, 2007).
Enhanced physician-patient communication is seen as a positive outcome. Legalization of physician-assisted death in Oregon has not undermined growth in palliative care services and notable leadership is acknowledged in opioid prescription per capita, hospice referral rates, home deaths, training of palliative care physicians and organized statewide approaches to the Physician Orders for Life-Sustaining Treatment protocol (Quill, 2007).
To qualify for physician-assisted death in Oregon a patient must meet the following criteria: be a capable adult; a resident of the state; and have a diagnosed illness likely to result in death within 6 months. A physician must request to assist in a death twice verbally, at least 15 days apart, and provide a written request. Furthermore, the must be consultation with a second physician to confirm diagnosis and prognosis, and the ability of the patient to provide informed consent (Gallagher, 2015).
The Oregon Public Health Division reported that during 2014, 155 prescriptions for lethal medication were written compared to 121 in 2013. In February 2015, at the time of the published report, 105 people had died from ingesting the medications prescribed during 2014 under the Dying with Dignity Act. Thirty-seven of the patients who received DWDA prescriptions did not take the medications and died of other causes.
Our future with physician-assisted death is unfolding in Canada. We will look to other jurisdictions, with years of experience, for guidance in how we choose to implement policies and practices. The experience garnered through the trials and lessons learned by others will enable us to initiate physician-assisted death with the most confidence possible and appropriate supports in place.
Bernheim, J.L., Chambaere, K., Theuns, P., Deliens, L. (2014). State of palliative care development in Europe countries with and without legally regulated physician-assisted dying. Health Care. 2(1): 10-14.
Bernheim, J.L., Distelmans, W., Mullie, A., Ashby, M.A. (2014). Questions and answers on the Belgian model of integral end-of-life: experiment? prototype? Bioethical Inquiry. 11: Gallagher, R. (2015). Physician-assisted suicide and euthanasia: the issues.
Ganzini, L., Nelson, H.D., Lee, M.A., Kraemer, D.F., Schmidt, T.A., Delorit, M.A. (2001).
Oregon physicians’ attitudes about and experiences with end-of-life care sine passage of the Oregon Death with Dignity Act. The Journal of the American Medical Association. 285(18): 2363-2369.
Lachman, V. (2010). Physician-assisted suicide: compassionate liberation of murder? MEDSURG Nursing Journal. 19(2).
Quill, T.E. (2007). Legal regulation of physician-assisted death – the latest report cards. New England Journal of Medicine. 356(19).