Embracing Life and Death

Feb 6, 2015, the Canadian Supreme Court ruled that physician assisted death and euthanasia legal prohibitions are illegal.

Section 241 (b) of the Canadian criminal code says that everyone who aids or abets a person in committing suicide commits an indictable offense. Section (C) says that no person may consent to death being inflicted upon them.

This section of the criminal code was deemed to violate the Canadian Charter of Rights section (7). Specifically the Right to life, liberty and security of the person (fundamental justice) was deemed to be unjustly infringed upon by the section of the criminal code.

In their ruling the justices stated in part: “A permissive regime with properly designed and administered safeguards was capable of protecting vulnerable people from abuse and error. Vulnerability can be assessed on an individual basis using the procedures that the physicians apply in their assessment of informed consent and decision capability in the context of medical decision-making more generally.

Physicians cannot be compelled to provide assistance in dying.

“An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. Leaving people to endure intolerable suffering, it impinges on their security of the person. The ruling in effect said that physician assisted death and euthanasia is no longer illegal and that adults with enduring, intolerable suffering, who clearly consenting can request that their lives be ended. An individual’s response to a grievous and irremediable medical condition is a matter critical to their dignity and autonomy. Leaving a person to endure intolerable suffering impinges upon their security of person as outlined in the Charter of Rights.”

Global Issue

The Canadian Supreme Court ruling gave the country’s Federal and Provincial governments 12 months to enact legislation to allow physician assisted death and euthanasia. As of January 2016, the Canadian Supreme Court had granted a 4- month extension to the governments to complete the task and ensure that the rights under the Charter of Rights are maintained.

Other legislative bodies have recognized this issue and enacted their own permissive legislation, including the U.S. states of Oregon, Washington, New Mexico, Montana and Vermont. In South America, Colombia has passed similar laws. While in Europe, Belgium, Luxembourg, Switzerland and Netherlands each allow physician-assisted death and/or euthanasia.

Great Britain’s High Court did accept that the absolute prohibition on assisted dying did breach the patient’s rights but found existing safeguards insufficient to protect the vulnerable and directed that the government develop appropriate safeguards. Other legislations have enacted legislation that have cemented the prohibition on physician assisted death and euthanasia.

OPINION POLL: Hypoxic Drive Theory: Myth or Reality

Necessary Medical Consideration

As time goes by, the “right to die” by physician-assisted death or patient-requested euthanasia is becoming a necessary consideration in all aspects of medical care.

Respiratory therapists, throughout their long and intense training, are taught to ensure the sanctity of life, the need to protect the vulnerable, and to do no harm. We are taught to ensure that we understand the reasons behind the orders we receive, that the physician writing the order has the knowledge and ability to write valid orders and that the order received is not harmful to the patient. Informed consent is a keystone to a respiratory therapists practice – the patient must agree to the risks associated with the procedure or treatment before it can proceed.

On the surface ,these pillars of practice collide with concept of physician assisted death or euthanasia. However, in reality, the practice of death as a secondary outcome of a treatment ( such as pain medication) or the withholding of interventions is common. It is not uncommon that the aggressive use of opiates to treat pain and discomfort results in a shortening of a patient’s life.

It is accepted that the “non-intentional” shortening of life is an acceptable outcome in the efforts to treat pain and discomfort. It has been accepted ethically that withholding what is deemed to be futile interventions or treatments (including mechanical ventilation). We are now faced with integration of physician assisted death or euthanasia into our practice matrix.

The question facing respiratory therapists is: How do we integrate the active act of ending a life in to our practice? The question of legality has been settled in Canada by the Supreme Court, but what has not been addressed or settled are the ethical implications!

For the majority of respiratory therapists, we have encountered many clinical situations where we have questioned the ethical choices made in offering various futile interventions or therapies. We have often wondered if there were alternatives to these hopeless interventions, would the patient take them – for some, a painless death may be an acceptable choice. Not being able to offer this as an option has shaped how we practice and what options we offer to the patient.

The legislation does clearly spell out that the person requesting physician assisted death or euthanasia must meet the test of capacity, to understand and give consent, to be assessed as not being coerced ( not meeting the vulnerable category) and to have ” a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.”

New Policies and Procedures

The question then becomes is that if all of these criteria are met, how will I, as a respiratory therapist, react to an order that is part of actively taking a life. Departmental policies and procedures can only go so far in addressing the ethical challenges these orders will create.

The decades of developed best practice runs counter to the concept of actively taking a life-and this is the challenge facing the respiratory therapist. We have not been trained or prepared to integrate this new change into our practice.

Although the actual implementation is still months away, now is the time to start preparing staff, policies and procedures and for consideration of what to do if a therapist has a conscious objection to participating in this act. For some it is religious based, for others it runs contrary to their social beliefs and for others it is fear of litigation. I am sure there are other legitimate reasons for objecting and the development of policies and procedures needs to address these.

For those that do not have objections or barriers to providing , what is now an approved standard of care, we need to look at training existing staff AND develop educational groundwork for new therapists entering the workplace.

Dave Swift, RRT, is campus coordinator, professional practice respiratory therapy, at Ottawa Hospital – Civic Campus, Ottawa, Ontario, Canada. He is also respiratory therapy lead/subject matter expert, for the National Office of the Healthcare Emergency Response Team, Public Health Canada.

About The Author