Dear colleagues,
The Supreme Court of Canada’s ruling that struck down laws prohibiting physician assistance in dying (within certain parameters) has ignited debate and national discussion about what it means to have a good death, and Canadians’ right to one.
I don’t think we can talk about medical assistance in dying without also considering the areas it intersects. This includes things like a national seniors’ strategy (as brought to prominence by the Canadian Medical Association), opioids and strategies to manage pain in different populations (like cancer, chronic disease, etc.), and moreover, palliative care services1.
A report released by the Canadian Cancer Society earlier this year highlighted nationwide inequalities in access to palliative care services, and significant disparities for this care across the country. The Federal Government campaigned on a promise to infuse three billion dollars over four years into home care services. Health Minister Jane Philpott, as recently as last month, restated the government’s commitment to bolstering palliative care in a new health accord with the provinces. Discussions are ongoing.
I firmly believe that improving, extending and investing in palliative care services is paramount in order to properly address questions in medical assistance in dying. I don’t think patients or families should be put in the position of having to choose between unreasonable pain and suffering, or applying for medically-assisted death. I think palliative care, based on good Palliative Medicine, needs to be available to all patients to help them with end-of-life decisions and actions.
I say these words as someone who spent his professional practice seeing the positive effects of good palliative medicine and the dreadful consequences of its absence.
As some of you may be aware, the bulk of my fulltime professional practice as a clinical hematologist was devoted to the care and treatment of leukemia and other hematologic malignancies, usually in the context of a stem-cell transplant program. The patients that I cared for required, accessed, and benefited from palliative care services. Part of my commitment to patient care has always been to make more and better palliative care available.
As the nation continues to discuss medical assistance in dying, palliative care services and support must also be brought to the forefront. Palliative care services need to be made more accessible to all Canadians and available at earlier stages to provide symptom management, assistance in dealing with psychosocial issues and/or spiritual care. These services are important components of quality living and, when the circumstances require, comfortable death.
Sincerely,
Andrew Padmos, BA, MD, FRCPC, FACP
Chief Executive Officer
Royal College developments that touch on palliative care include collaborations in education and training:
- Conjoint training program in Palliative Medicine: We have been in regular discussions with the College of Family Physicians of Canada about continuing the conjoint one-year training program in Palliative Medicine. This program has been available at several academic health centres for a number of years. While most of the trainees are from Family Medicine, it has been an important opportunity for Fellows who want to do more in this important area.
- Subspecialty in Palliative Medicine: Another dimension is the recent development of a Royal College subspecialty in Palliative Medicine. We look forward to this subspecialty providing opportunities for research and academic leadership for palliative care in Canada.
- MOC and CPD programs: In addition, we will explore how our Maintenance of Certification (MOC) Program and continuing professional development (CPD) activities support end-of-life content areas. We would like to be able to produce more modules in our bioethics program directing our practising specialists to useful resources in the field of Palliative Medicine and medical assistance in dying.
1Both a national seniors strategy and pain management (with and without the use of opioids) are important areas that are being discussed and actioned by medical organizations, including the Royal College’s new subspecialty in Pain Medicine. Each one could be a topic in and of itself. The focus of this message on palliative care should not be interpreted as it having more importance than these other topics.
June 18, 2016 at 12:43 pm
Good palliative care should include pleasant and private enviroment in a busy general hospital, not just a designated bed or section among high traffic acute care surroundings. When possible, this should be extended to home care with adequate support for the family of the dying. Administrators should be aware that providing these is a lot cheaper than fruitless acute or subacute care. The palliative care beds at Vancouver General Hospital have bright and great views, while some other palliative care units I have seen are tucked in the back dark corners of the hospital.
June 7, 2016 at 8:43 pm
Let us be clear about” medical assistance in dying”. Is physician assisted suicide included in the above. If so ,it is morally, ethically, and medically wrong.There is no question regarding palliative care for the dying so that a dying person may die with dignity and compassion in the caritas of palliative care personnel and family members.
June 9, 2016 at 3:45 pm
Bang on!
June 7, 2016 at 12:23 pm
Thank you, all, for your thoughtful and sincere comments. I’ve read each and every one of them with great interest. Your obvious care for your patients and their wellbeing is very heartening. End-of-life care – all aspects – is an important conversation to have. We know there are some gaps and deficiencies, especially in access to key services. We also know there are more care elements that haven’t to date been at the forefront of discussions about medical assistance in dying. I am encouraged by the respectful dialogue on this post and am hopeful that we, as medical professionals, will continue to advocate for the best quality of care for all Canadians at all stages of their lives and illnesses. – Andrew Padmos, CEO
June 5, 2016 at 9:17 pm
Well said, Dr. Padmos. When did we cross the line making terminating a life an acceptable treatment?
June 5, 2016 at 9:41 am
Palliative care is the ONLY way for physicians.
June 4, 2016 at 3:53 pm
I entirely agree with Dr. Padmos that palliative care is a critical component of good medical practice, and should be available to all who require it.
But what is never acknowledged in this discussion is that for some, the prospect of needing palliative care is the reason they seek assistance in dying. There is far more to end of life care than control of physical suffering such as pain, nausea, dyspnoea, dysphagia etc. It may be that these symptoms can be mitigated by good palliative care.
What cannot be mitigated by any level of care is loss of privacy, dignity, independence and purpose without which, for some, life itself becomes a form of torture.
The medical community will never reach consensus in this debate, so instead can we not agree that if those who prefer to prolong the dying process via palliative care should have it, but it should not be forced on those who would rather be dead.
The decision has already been made by the Supreme Court, and I am sorry to see organized medicine trying to limit and restrict the legal and moral right of all Canadians to end their lives at the time of their choice. Whatever happened to patient autonomy?
June 4, 2016 at 3:08 pm
I wonder how mid or late career physicians can add Palliative Care competencies/certification to their specialty without having to take a year off work. This would help promote access to Specialist Palliative Care.
June 7, 2016 at 12:22 pm
Hi Janis, you’ve brought up an interesting consideration that I think warrants further reflection. I’ve shared your comment with the manager of our specialties unit. I will also share it with our director of continuing professional development. – Andrew Padmos, CEO
June 4, 2016 at 12:03 pm
Dr. Padamos,
At the end of the day the conversation is a philosophical one, in terms of the worldview we use to advocate or reject gray zones presented when we articulate our thoughts around the emphasis that the state should place on palliative care or euthanasia. The way how one interprets -the fundamental questions of the universe, the value of the human person and its capacity to produce reasoning that provides feedback to nature –certainly leads to a position that accepts physician executed death of the terminally ill. I believe we are not there yet, we have not found the answers to the questions noted above. The Canadian State must respect freedom of conscience. We should not ignore past experiences where other states have abused immensely political power and military control, just to end using patients and health care providers as expressions of their lack of humanity. Ricardo A. Cartagena
June 3, 2016 at 10:16 pm
Dear Dr Padmos, Thank you for your statements regarding palliative care.
When I was in practice i also wanted to do as much as I could to encourage my patient each step of the way.
June 3, 2016 at 7:38 pm
Well said. The Senate Committee several years ago under Sharon Carstairs, revealed the disparities in access, and suggested that less than a third of patients access quality palliative care resources.
I believe that a Palliative Carr consultation should be a prerequisite to even starting the discussion about physician assisted death, just as there’s the requirement for assessment by two independent physicians.
Ian Reid
June 3, 2016 at 1:55 pm
Andrew,
In your laudable zeal to enhance palliative care, even to make it universally available, you fail to account for the occasions, not rare, where a doctor assisted death is the most humane solution. PLEASE, re-listen and watch my friend and former colleague, Donald Low, in his last minute plea for release from suffering. He had all the tools of palliative care available, but he needed more than that. The Supreme Court has acknowledged his right, and the profession must accede to this judgement. This need not be an either or situation,and “perfection” should not be the enemy of the good.
June 3, 2016 at 12:33 pm
That you, Dr. Padmos. How did we (as a society) reach the point of concluding that ending a life to relief suffering is right ? Palliative care is the answer. It is not just about eliminating physical pain, but the process of dying also provides the opportunity to relive emotional and psychological baggage intrinsic to our human state. It is usually during the dying process that we beging to address these issues. Palliative care provides the best environment for this to take place. Dying in peace is learning to accept our mortality and to help our loved ones to except theirs.
June 3, 2016 at 11:15 am
We agree with this position. It is stated very well, and improving access to comprehensive palliative care in urban and rural areas should be a major emphasis as medically assisted death legislation is brought forward through our legislators.
We also must not abandon our traditional requirement for competency to decide one’s care.
Eldon Tunks (President, Canadian Academy of Pain Management)
June 3, 2016 at 11:08 am
I am a psychiatrist. I work to help people find solace and dignity in experiences fraught with suffering and distress. Palliative care works towards similar goals. Just as we seek to prevent suicide through appropriate psychiatric care, we need to strive to prevent medically assisted dying by providing access to appropriate palliative care. Thank you for your message, Dr. Padmos.
June 3, 2016 at 8:11 am
Thank God that the suffering have a champion in you, Andrew, and others who are speaking up here and elsewhere. The plight of those who need palliative care is not addressed in the main stream media, nor in the minds of the politicians. This should be a major platform item for the RCPSC, the CMA, and the provincial bodies. Please do not let your message drown in the cacophony and other noise out there.
June 3, 2016 at 7:15 am
Consideration of medical assistance in dying is a moot issue at the best of times. We must protect the position of those physicians who do not embrace the concept because of their reverence for life and their desire to sustain and support life – even that which is ravaged by disease.
Consideration of medical assistance in dying in the absence of properly designed and adequate palliative care is like looking to amputate a lower extremity when there has been poor and inadequate treatment of an arthritic knee … it is absurd!
June 3, 2016 at 6:47 am
I am a full time Palliative Care Physician involved in clinical practice and teaching at all levels.
Your support and advocacy is deeply appreciated, Dr. Padmos. Thank you.
June 3, 2016 at 5:18 am
I totally agree with your comments. Palliative care IS medically assisted dying.Its lack of adequate availability to all dying people is a chronic shame to our health care system.Thank you for championing this. Dr John Stewart
June 1, 2016 at 1:28 pm
The Royal College is 20 years behind the curve on this issue. I am thrilled to see the change in attitude!