The current state hasn’t effectively dealt with disagreements between treating physicians and family. Any proposed approach will have to acknowledge and deal with both parties legitimate concerns, values and feelings in order to be helpful.
Good communication is the foundation of a reasoned decision. Unfortunately, end-of-life discussions for many chronic conditions do not happen in a timely manner with the patient and the family. We must routinely incorporate these discussions along with the advance directives way ahead of time. This will facilitate the process for understanding and appreciation of medically futile interventions – i.e. prolonging the dying process. In a publically funded system, sometimes clinically unnecessary investigation and treatment are pursued without credible justification. Public dialogue around these issues with the funders and providers are crucial.
I found the Hassan Rasouli decision disappointing, not so much for what the justices actually said but how it is in danger of being misinterpreted. All they really ruled is that physicians cannot unilaterally withdraw life sustaining therapy. It is likely to be misinterpreted as a family’s blanket right to insist on futile therapy.
I would hope that any CPSO policy would strongly support the physician’s ethical and societal responsibility to discontinue futile therapy. Where families disagree, the justices have laid out a clear (if expensive and time consuming) process to resolve disputes, something that should be stressed in any CPSO policy.
There is the more challenging dilemma of the waste of health care resources generated by religious or philosophical beliefs.
The cost of health care is unsustainable. We desparately need a societal conversation on the topic. But then we need to move on to solutions. There needs to be a cost/benefit analysis brought to all the decisions we make in health care, not just at the end of life.
Other publicly funded jurisdictions like education and the environment are suffering financially in favour of luxurious and arguably wasteful health care.
Stating discontinuation of care should be done based on “lack of improvement” is immoral and not ethical. I’m appauled at the college for such a statement! Sometimes stability is all we can achieve and may be better than worsening. Improvement may not always be achievable but to discontinue care based on lack of improvement is assine!
I start with the position that human life has an intrinsic value that warrants guarding. Suffering, while not welcomed by us, can have its own healing benefits. All people relating to an “end of life” patient or family must do so with respect & sensitivity, with special regard to the explicit and implicit wishes of the patient.
I have requested that life supports be withdrawn when there is a consensus that conscious interactive life (not to imply “normal or productive”)is no longer likely. More resources are need for hospice and related services.
Any medical ethics and legislation that will end in legalizing “physician assisted suicide” has many more social and ethical dangers than the proponents are willing to acknowledge. I do not believe that withholding treatment for the “terminally ill” is the same as assisted suicide. We must recognize that no one can stop our eventual death, nor has the right to “play God” in actively hastening death.
The need for society to discuss the allocation of limited health care resources applies to more than “end-of-life” situations.
Even with my perspective, one can never avoid all difficult choices, or avoid coming in conflict with family memebers with very diverse opinions, i.e. differing with the physician and/or amongst themselves.
I am a pediatric anesthetist, so I am more involved in this topic looking after our young patients. I am very interested with the concept of “speed” with the family. Although most patients, even very young ones, realize that their life is inevitably going to end soon, many families do not go through this process at the same pace. They need more time. Another concepts is to be discussed as well, the idea of futility in the medium term . A patient born with a major known congenital disease (eg trisomy 18) which always causes very severe development delay and many other organ dysfunction or malformations is going to die inevitably in the medium term. Families do not have this concept of the medium term. Their experience is a day to day one, as long as the baby survives the day, there is “hope” even if it gives the patient a very painful life. None of the families (even when parents are both doctors) I met had come to terms with this medium term concept. They always hoped for a miracle. As a result, some DNR orders that are signed are reversed as soon as the patient gets temporarily a little better, or if the patients gets worse and is within range of “effective” resuscitation. I do not know what is to be done in these cases, I would welcome some advice.
I do think we need to have a societal conversation about the allocation of scarce medical resources. I think this article is excellent and very well balanced. This is a very tough issue that we must talk about. It is too expensive and hard on everybody when treatment that is futile is happening. I do quite a bit of home palliative care and I find that the oncologists are doing chemo way too late in the course of the illness; sometimes within a week of the person passing. This does not allow the patient and their family to truly face the inevitable. The oncologists do not want to have those difficult chats and stop therapy even though the therapy is making them very sick.
When a patient is asked to give consent for a risky procedure, I think it would be prudent for the responsible physician to also obtain clear, written advanced directives from the patient/SDM, pre-operatively. It would help with cases like Mr. Hasan Rasouli. I do not know how symptomatic he was from his benign brain tumor and if surgery was the only option.
I have buried a father, a wife, a son and a grandson.That they all died young is not an evil or tragic event. It is what it is. Death is normal and natural.
I puzzle at how shallow and fearful so many in our society are and how irresponsible many are. They would expend scarse resources without any material hope of benefit on someone in their own attempt to deny our common mutual mortality, this is one root of the difficulty in moving this discourse ahead.
Until there is clarity about whether an attempt at resuscitation is required to be offered to every patient, we as physicians will create more situations where the issue of possible futility arises. We do not have a standard of care for the dying yet many physicians believe they must offer an attempt at resuscitation. By offering this, we imply that it is a reasonable alternative but we are surprised when families and patients say yes.
I think we have to be very careful with creating a policy around this issue. It has two sides.
We should not create a policy which gives the patient an unrestricted right to demand assisted suicide while on the other hand we have to ethically decide which investigations/interventions are prolonging the dying process.
This decision should not be based on weather the medical interventions are publicly funded or not as this makes the issue murkier and I for one am not ready to play god!
Physicians should not to be put in a position where they are forced to make medical decisions according to a policy or according to patient demands, against their better judgements.
We must routinely incorporate end-of-life instructions along with the advance directives, beginning the discussion as soon as the patient and family can manage, when an illness is identified as terminal. The ongoing discussions should include the patient’s wishes on physician-assisted suicide as well as withdrawal of life-sustaining therapy. The patient’s religious or philosophical beliefs are of the utmost importance and, when stated clearly and agreed on by treating physicians, should direct action. This does not help when only family members are available, but we need to begin codification somewhere.
Extending end-of-life instructions to become part of the consent process whenever surgery or invasive investigation is proposed may make the concept less shocking and more accepted as part of normal medical care.
I agree that death should not be prolonged and I believe that the patient’s comfort during dying is paramount.
Having watched a family member die slowly in hospital of liver and renal failure and whose death was inevitable, I wondered if stopping IV hydration created suffering in them that was unnecessary. It seems to me that providing hydration during dying is part of compassionate care and should be retained when all other measures are stopped.
They will die nonetheless either way but dehydration seems to me to inflict unnecessary discomfort during the dying process.
medical futility article was very well written. I have not been following the other articles, however I sincerely hope that end of life care does not include, physician assisted suicide. Medicine is a second career for me, and in my first career as a nurse for over 20 years, I had many experiences helping patients and families deal with death and dying. Each experience is very unique and personal, however as health care professionals it is our responsibility to both help give direction and guidance to families, as well as be realists and gatekeepers of our limited finances. As a Christian doctor I do not wish to impose my beliefs on anyone and have always supported patients and families in their difficult journeys toward death. As health care professionals our focus is on aiding the body in healing and when that is not possible, to provide expert care and advice in the death process.
thanks for reading, keep up the good work
My son taught me that it takes a year for a tree to die, no matter the cause. It is this way with people too I think. Humans think of death as a moment not a process and we are very poor as health care providers at identifying the last year of life. Health care providers spend a lot of money treating conditions that mark a life coming to the end. Our research and treatment in cardiology has prevented a lot of sudden death and our reward has been watching people die a slow death by heart failure. I would never want to participate in assisted suicide but there must be some compassionate middle ground.
I liked the article’s emphasis on pondering the goal of continued care, and its likely outcomes. As a physician faced with a spouse in a locked in state years ago, I would have found a prompt, frank discussion of likely outcomes very helpful, rather than having to hunt down the statistics on the internet. Eventually, I got that discussion with his physician, and concluded that continued care was futile based on my knowledge of how this man would suffer in an inactive, non-communicative state. I’m glad that there was an effort to understand my position, that it didn’t become a legal issue, and that I was reassured that the most difficult decision of my life was ultimately a reasonable one.
In my experience with late life care and treatment, the conversation best begins with what the patient wants. In the case of the demented patient, the focus is on what the SDM thinks the patient most likely would want. Then the recognition that decline and death are inevitable outcomes eventually. Death is a process rather than an event. The prolongation of the process is not a preservation of life but a lengthening of the misery or suffering. These concepts need to be instilled in the relatives with sensitivity to the level of their discomfort with the topic. But, none the less, frank and clear language is needed. This conversation begins as early as possible in the case of declining patient that is not responding to treatment.
As a society we need to talk not just about what constitutes “futile” treatment, but also start thinking about ourselves, each individually, about what we might or might not want, what our own goals of care are. This applies for little questions such as when to stop or start the multitude of daily medications aimed at preventing that stroke or heart attack. It also applies to bigger questions such as resuscitation and mechanical ventilation in a variety of circumstances. One always reserves the right to change one’s mind, of course, but to start thinking about it seems important to me.
With respect to “treatment is futile.” To talk of with-holding treatment is often problematic. Anyone beginning a conversation that way might well expect to run into difficulty. Beginning by asking what are the priorities or goals of care might lead to the same conclusion (e.g., that resuscitation or mechanical ventilation might be futile) but the philosophical orientation is more patient- or family-centered rather health-care-resource-oriented.
The Rasouli case got a lot of press, and raises interesting questions, but for most of us in non-ICU settings, the challenge with resource allocation lies more routinely in determining the context of care than the content of care. i.e., hospital vs nursing home; hospital vs home; community hospital vs tertiary care centre, etc.
In your article in the College publication MD Dialogue, vol. 9. Issue 4. 2013) you invite discussion in regards to the issue of “medical futility”. As someone who has been working in the field of Palliative Care for close to 25 years, I find this article disturbing. Also, it seems to me that several concepts are mixed together rather randomly in this article.
For example, article is inviting the members of the college to think about is “medical futility” since its main title would suggest so, yet on the first page it mentions the complex situation that arises when “the physician, the patient, or the patient’s Substitute Decision Maker (SDM) believe that treatment is futile”. I would like to point your attention to the fact that he “medical futility” and the “belief that treatment is futile” are not one and the same conceptualization. A few lines down the article introduces the issue of “prolonging death”, which again has nothing to do with the medical futility.
Also, somehow I cannot get rid of a feeling that there is an underlying agenda being put forward here. “Allocation of scarce resources in the end-of-life context” is mentioned. “Sound institutional policies” along with “misinformation” are mentioned as well. Well, in the same issue of “MD Dialogue” the fact that the College’s main mission is to serve and protect the public is mentioned more than once. Really? History has shown what happened when an infamous politician instructed physicians to make a decision, based on human deliberation, as to who with incurable illness should be granted a mercy death. Just exactly what are we looking at here? Not sure it has to do with practicing medicine. Or protecting the public.
Limiting the argument to the concept of the medical futility, it is my opinion that such concept is based on the paternalistic medicine of the past. I totally sidesteps the fact that in palliative care the scope of practice deals with much more than the strictly objective “medical” domain. Strictly speaking the “science” of medicine as practiced currently focuses on the physiology and pathology of the living organism. Most of the time it means that the objective Cartesian universe of mind-body dissociation is followed. Yet that is a philosophical concept that is more than 364 years old!
Let’s look at the Medical Futility definition as determined by the CPSO (MD Dialogue, vol. 9. Issue 4. 2013, p.350:
“treatment is generally seen as medically futile when:
• it offers no reasonable hope of recovery or improvement; or
• the patient is permanently unable to experience any benefit.”
As a palliative physician to relieve my patient’s suffering I must provide treatment that clearly will benefit my patient along the concept employed by the Medical Ethics. There always must be a benefit to the patient from what I do as a physician. By that I mean benefit along all domains of the human being, benefit to the person as a whole. Not just along the physiological/pathological domain. It sometimes involves a lot of work, work that is not necessarily captured by the billing system, work that we are not necessarily trained for as physicians to be able to do it right. It involves a lot of interpersonal work.
It is after all about the Patient. Not about us. Not about politics or bureaucracy (at this stage at least). The treatment we provide should not benefit us or other care providers. Or the system. If treatment is instituted in a premeditated way that is designed not to provide any measurable benefit to the patient that would be unethical from any angle. The treatment we provide should be along patient’s values and goals of care. We should clearly define the goals of care that the patient has. Patients should be informed about the care we are prepared to deliver and informed about the scope of our practice.
There is lots to be done when nothing else can be done. Physicians are not particularly well trained to deal with chronic illness, suffering, and incurable disease. Futility of care should not be a consideration. It may be seen as violating certain fundamental personal needs our patients have. It invites conflict and anger. It destroys the physician-patient relationship. It should not be something that anyone should be deliberating on. The College is not exempt.
Perhaps the discussion should not be about the medical futility of care. Perhaps we could talk about aligning the goals of care, treatment outcomes possibilities and probabilities, our professional recommendations, and the limits to what we can or cannot do medically within the system of delivery we are working in.
We live in a country with scarce resources. In a public system where funds are allocated by a central site who is responsible for governing the use and allocation of scarce resources. If an epidemic were to arise and resources were very limited would we allow a patient with little chance of recovery ongoing life support when others could be dying in the emergency department? I think too many patients with chronic illnesses are not given the opportunity to consider end of life care and if talked about in an open and non-urgent manner, may help to alleviate some of the misconceptions surrounding death and dying.
In Hong Kong, the Code of conduct is such that withdrawal of treatment if such is futile is not professional misconduct.
I am a bit confused as to why the Canadian judge would set such a precedent case which may make life difficult for doctors and relatives.
I suspect that many of the problems occur because of poor communication early in the patient-family-physician encounter. It is immensely difficult to try to regain lost ground – lost because of poorly worded or throwaway comments made in emergency or early in the ICU stay – after the relationship has been damaged. I work in palliative care and the single most important thing I can do for a family is sit down and listen to their entire story, validating their walk through the story. Only after we have done that work can we progress to talking about “how then shall we live?”. My plea to my colleagues on the very front lines would be to take a bit more time and care in wording initial pronouncements about possible outcomes.
There is nothing unethical or immoral if end of life is necessary to alleviate suffering from terminal and incurable disease. One must remember that the patient has the right and that suffering is not only for the patient but also the family that surrounds the patient. The decision to end life must come from the patient only and the physician involved must have sound knowledge about the natural history of the illness and treatment options.
Recent example in LTC:
1. Often one or more SDM’s simply cannot accept the looming loss. Unfortunately the SDM can feel that they are making the decision (stopping HDC) that will result in death and are “being asked to play God”.
2. Ambulance attendant, with no context regarding the end-of-life dabate of the previous two weeks, looks at the patient and states “Why is this man not getting dialysis!” This sentence undoes all the work and attempts at communication over four 30-minute phone calls with this SDM
3. Phone attempts by the MRP to inform the nurses and MD who will be recieving this patient in ER are not accepted/responded to. Transfer notes are not always able to communicate the underlying issues
We need to work as a health TEAM, including all players, and treating everyone with respect, to achieve improved communication with families. It will still not be easy, and on occasion impossible (given the psychological backgrounds unique to each circimstance). But dismissive comments regarding one provider made by another serve no good purpose. On those occasions where the hospitalist has contacted me regarding transfer especially with regard to palliative patients, or has accepted my call, a more satisfying outcome is often achieved. A big time-saver in the long run.
The comments already posted illustrate that not even the physicians are in agreement regarding these issues. Communication can therefore only go so far. But thoughtfulness and courtesy along with timely discussion well in advance goes a long way. If we are not certain if such discussions have been held we should ask, and reach out to our colleagues first before assuming incompetance on the part of others.
Healthcare money is limited. Demands on healthcare dollars will increase in the future. Current rates of healthcare spending are unsustainable. Mandate advanced directives for patients when they are capable, offer them a tour of their local ICU department to understand what it means to be on life support. Place some of the financial burden of ongoing medical care on the patient/family based on their ability to pay. Increase privatization of healthcare for non-essential services to take pressure off public spending. Respect doctors judgment, authority and decisions and protect them from legal actions or answering to frivolous complaints.
Early and frequent communication about the goals of care, with the patient and his or her family is of paramount importance….This should normally diffuse ambiguity about care near end of life.
Physicians must schedule uninterrupted time and clearly describe the possible and likely outcomes with status quo therapy vs. (gradual) withdrawal of care. Possibility and likelihood of suffering should be presented. Time must be given to address expressed concerns and ideas.
Sometime families, SD makers, need a second medical opinion before withdrawing care. This request should be understood and supported (rather than becoming defensive).
Scarcity of resources is rarely a terrific discussion to have, as it exacerbates anxiety. However, if there is another patient critically ill who requires ICU care and the vented patient is near EOL, then it is fair to present that information to the family/SDM in most cases. Normally a clear outline of the palliative care the patient will receive once extubated will help alleviate concerns of suffering.
I am an intensivist. I hope the CPSO, the CNO, and in due course hospital policies make the following changes explicit:
1. “full code” is clearly spelled out not as a demand for CPR, but rather candidacy for CPR. For example, if a decapitated “full code” patient MUST receive CPR, every one of us would see this as inappropriate, but families may interpret “full code” as a promise of delivering CPR, at least briefly.
2. a physician who wishes to stop “futile” treatment could certainly be compelled in Ontario to go to the CCB as the Supreme Court implied – that is perfectly acceptable.
3. a physician who wishes not to offer “futile” treatment should be compelled to go through some reasonable steps (for example, communicate the decision to the family, get a second opinion, consult with facility policy if applicable, seek another provider willing to provide “futile” treatment). Once these steps are undertaken, all the regulatory agencies should explicitly endorse this stance in Ontario.
The term ‘medical futility’ is frought with danger.What is considered futile today may be considered non futile tomorrow.In acute cases it is extreamly dangerous.Ex. non breathing person {hyperglycaemia}Even in chronic cases who is to decide treatment is futile? If it is too expensive to carry on it is honest to say so rather than hide under the cloak of ‘medically futile’
As a longtime member of Dying with Dignity, I would like to have the option of a quick and painless death provided by a doctor when ‘my time comes’. I am very supportive of the current move to make this legal in Quebec. We need the same action in Ontario.
I am currently a healthy senior citizen and this issue is extremely important to me.
My mother was diagnosed with a glioblastoma multiforme, and did not meet the criteria for treatment. The doctors in presented all the information to her in such a way that she was actually able to choose not to be treated without them actually telling her that they would not treat her. I thought it was very gracious of them. I will forever appreciate that.
I firmly believe that the individual should have the right to choose death with dignity. I for one would hate to be stewing in my own mess – a burden to a health care system already taxed to the gills – a burden on my family emotionally and financially when there is no hope for my recovery.
My sister died at age 45 after an initial late diagnosis of metastasized breast cancer. She received palliative care at home but endured many days of pain which could not be alleviated without the quantity of morphine which would have endangered her life and was for that reason withheld. She had been diagnosed with terminal cancer. What conceivable purpose did it serve to force her to endure a final agony which could have been avoided. I believe in end of life decisions made in conjunction with medical diagnosis and allevation of needless suffering.
Leaving people dying in Long Term Care Facilities which do not have the man power or the knowledge on how to care for them is cruelty, we need to address this and have a safety net for those persons who do not want to suffer this indignity. If a person has requested to allowed to die as an alternative to living this way I think that is their individual right to do so and to be given help with dying if that is their wish. We need more discussion on this issue.
I live in British Columbia and believe that it should be discussion between patient, family, and primary family physician. I feel if a patient is terminal or has severe chronic condition such as ALS, they should be able to make the decision to end their life. And that it should be done with dignity, respect, and on the patients terms.
I have watched too many friends and family members end up in Palliative Care and their is no dignity there, they try, but it is institutional. I feel when the patient is ready they should be able to go to bed and take a bigger dose of morphine and just go to sleep peacefully and quietly.
I believe that Euthanasia and Assisted Suicide should be a part of the continuum of care, especially in situations of medical futility. It makes little sense to attempt to force a situation to be prolonged unnecessarily in a way that costs both the patient and the health care system.
Thank you all for your careful and considered responses . I have been an I.C.U. /E.R. nurse for 40 years .What I have learned is that it is really all about communication . In the current system patients and families as well as health care providers suffer often as a result of confusing “caring” with “curing”. We do not ever cure anyone of “death” ,trite as that may sound ,but we must always seek to get at the heart of “what the patient wants” and do our utmost to provide that. Legislators , politicians , and those in their ivory towers must and will eventually be forced to respond , make some difficult choices . As healthcare providers , our choice is clear . We must continue to advocate for each patient individually , especially when their choices would not be our choices .We are not the “gate-keepers ” nor “the angels of mercy” we are simply people who care .
I have given clear instructions to my next of kin about end of life issues and I would want any decision to terminate care, given by my legal representative obeyed.
My son was admitted hospital in 2004. He was dealing with a neuro-disability that had not been diagnosed specifically. He was ambulatory at the time, but deteriorated quickly. He, although nonverbal, turned down tubal feeding. There was no indication that the hospital staff felt there was any hope. He was alert and able to signal to me. We had him transferred to Palliative Care. At no time was intervention suggested and within two weeks he died. He was 37 years old. No heroic efforts to save a young man who was relatively healthy a month prior to admittance. I am still stunned at how easy it appeared to be to allow this man to die. I have conflicting emotions and guilt as to whether I did all I could for him. I had a strong feeling that an accident had occurred in the hospital that he could not convey due to being mute.
Over 150 years ago, John Stuart Mill summarized the essence of the debate in one sentence: “Over himself, over his own body and mind, the individual is sovereign.”
My husband was diagnosed with prostate cancer and underwent chemotherapy and radiation. His cancer was the severe variety and eventually moved into the bones. He had made it clear that he wanted to die. Our doctor said he could do nothing. However when my husband was in the hospital having had a brain clot, and was on morphine but still suffered humiliation (he was a retired naval officer and commercial beekeeper)and in pain, our family doctor agreed he could stop the warfarin. He died due to a massive brain clot. His children and I rejoiced that he was free. He was 72 years old and had enjoyed a full, active and enriched life. We are forever indebted to the doctor.
I am very much in favor of end of life assistance. I think dying is as much a part of our health care as being born. When the chance of a normal life is futile, then we should let them go. At 92 my sister last year was in this position, ready to go, after a stroke and heart attack, and she had to live for 2 – 3 more uncomfortable weeks. She should have been able to have a needle to end her life with all of us standing around her singing and telling how much we love her. Some of us are not afraid to die. And, the words “Assisted Suicide” should never be used again with regard to end of life care. I hope that you will do everything in your power to have this changed. Maybe the Hipocratic Oath has to be changed to give the doctors the authority to do this. Don’t know how that works. Thank you for anything you can do to make this change in Canada soon.
I realize that this discussion is taking place on the CPSO website, but does anyone but me think it telling that virtually all respondents (except “Anonymous” and myself) are physicians? Why isn’t anyone talking to and listening to us, the families of patients? Or potential patients ourselves?
I remember a home care nurse being very angry with me for not authorizing my mother’s immediate move to hospital when the NURSE thought she should be going there, despite my mother’s very clearly and frequently expressed wish to die at home when the time came for her to die. I supported my mother’s end-of-life decision. No one supported me.
It seems that families are supported only when the families agree with the medical community’s views.
We were denied at-home palliative care in my mother’s last days and weeks. “Didn’t meet the criteria” — whatever that means. I guess just being near-death, and in pain from bedsores, inability to eat, etc. isn’t enough for someone to be considered palliative. I therefore have my concerns for when I get to the stage where I will need hospice / palliative care. If I can’t be sure I can end my life relatively pain-free, then I want the right to end it when and how I choose. I’ll find a way to do that, physician-assisted or not.
All that aside, I’d like a clarification of the statement “suffering … can have its own healing benefits” (Physician comment Jan 20). Healing benefits for whom? The family forced to watch the suffering? The patient who suffers into death, with little or no medical support? What are the “healing benefits” of suffering?
The medical community talks about the need for communication with patient and/or family. So far, I haven’t seen it happening. The experts are talking to the experts, with no one yet noticing that the rest of us are even in the room.
I agree with those who say this discussion needs to be opened up to everyone, and needs to be had earlier in the game. The question re end-of-life care should not come at the end, when patient and family are emotionally stretched. And any decisions re policy should involve discussion with, and LISTENING TO, family and patient, not just doctors.
My greatest fear is that I will be kept on tubes and machines against my will at the end of my life. I will do anything to avoid this. But please do not force me into the role of desperate dying senior.
Allow me the dignity of choosing the time, manner & place of my own death. It’s my life, and it’s my death.
I am a relatively young patient with terminal recurrent ovarian cancer. The only thing worse dealing with than my prognosis is the knowledge that I can not legally opt out of the paiful, degrading and hopeless living with late stage disease. I am neither demented nor suicidal. Yes, I signed DNR form and advanced directive; I can refuse food and drink. I need a better option to end my life when I chose to do so than messing with inert gases or smuggling barbiturates across the Mexican border. And I expect our politically-correct society to make this option available to me and to countless others sooner rather than later. And save a ton of money on palliative care in the process. Peace y’all.
Your body is nearly paralyzed and your lungs are slowly shutting down. You face weeks of agonizing physical and psychological pain as you slowly suffocate to death. Because of the risk of 14 years in prison, no one, not even a willing doctor, will help you to die. No one will help you even though you are a competent adult, who is fully informed about your condition and who voluntarily consents to someone assisting you to die. No one will help you even though you have a living will that states what you do not want to continue to live in this condition. No one will help you even though you have stated you want to die many times to doctors, your family and friends. No one will help even though you are not clinically depressed, but do not want to live in this horrifying condition. In Canada it is legal to take your own life, but if you are disabled or incapacitated, no one will help you to die. The overwhelming major of Canadians believe this situation should be changed. Do you?
Surveys shows that Canadians of all political parties overwhelmingly support assisted death and yet parliamentarians overwhelmingly do not. Do your elected representatives represent your needs?
Ideologues, zealots and religious fundamentalists do not support assisted death under any circumstances. Should these people determine how you die?
Who decides when to end your life if you are disabled or incapacitated: the government, bureaucrats, medical personnel, religious organizations? In a diverse country like Canada, should competent and informed individuals voluntarily decide for themselves?
Taking your own life is legal, but assisting another who disabled or incapacitated is not legal, even when that person is in intractable pain and wants to die and is competent, full informed and voluntarily consents. Does this situation discriminate unjustly against the disabled and incapacitated?
Where assisted death is allowed and adequately legislated and enforced, the disabled and incapacitated are less likely to have their lives ended illegally. Should Canada provide this protection to Canadians who are disabled or incapacitated?
Some people worry about slippery slopes (i.e., that any move towards assisted death will cause disastrous results) if Canada allows assisted death. However, evidence from other jurisdictions demonstrates that slippery slopes can be avoided with adequate legislation and enforcement. Should Canada allow assisted death with adequate legislation and enforcement?
Palliative care and pain doctors state there are situations where pain cannot be controlled. Should people be forced to endure agonizing pain or should they be able to decide when to end their lives?
We can prolong death and force people to endure excruciating pain with no quality of life, but wouldn’t it be better if the dying made their own end of life decisions?
Greetings,
I am writing in support of the principle of dignity in death.
My mother was living alone at the age of 82 years after my father’s death. One day, she suffered a stroke and heart attack simultaneously. My brother found her, hours later, on the floor of her living room. He called 911 of course, and she was taken to hospital. When I went to see her, I saw how damaged she was, and went into the hospital corridor to speak to the first nurse I saw, demanding that she not employ any heroic measures to keep my mother alive. It was futile. Mother developed pneumonia, which would have led to her death if left untreated, but they gave her antibiotics. She was later transferred to a nursing home, where she suffered for 4 long years, unable to feed herself, or speak, or use the bathroom,or get out of bed. She COULD utter the words, “Oh dear! Oh dear!” endlessly. She could also sing with us if we sang hymns by her bed. It was such an unnecessary purgatory for her to be trapped in. She did not deserve such suffering. I lend my full support to the notion that doctors should be allowed to, and willing to, hasten death for people who wish it, people who have no hope of recovery, and people for whom life is an intolerable burden.
Thanks for registering my opinion.
The medical team’s perception of futility should be given major weight because of their expertise but mstly because their opinion is more llikelly to be objective.
The emphasis should be on consideration of outcome – will the patient be better off as result of continued futile treatment?
I had personal experience in connection with the death of my father when one member of the family, who was the legal SDM, insisted that treatment continue. The result was two weeks of agonized dying.
When and if I become mentally or physically disabled I want to be in control what is being done to. I don’t ever want to into a home where you spend what’s left of your in God’s waiting room. It costs the taxpayer money that should be spent on other things and makes it so hard on the family (I know).I want assisted suicide to be in place. It’s already there except for the law. My mother suffered for years before going to a home where they took her off meds and gave her morphine to end her life. The problem was it took six years to finally make that happen.
Some would argue that it is acceptable to just let someone commit suicide on their own as it is now when they want to avoid end of life suffering. It is not possible for some to ‘commit suicide’ when they have reached a point of choosing death. That is what the Sue Rodriguez case was all about. Refusing treatment also does not work. That is what Margaret Bentley’s case is/was all about. Palliative Sedation? “Palliative Sedation: It’s Not a Panacea”. American Journal of Bioethics. June 2011. Within that paper: “While the intent of palliative sedation is to eliminate pain and suffering, a significant minority of patients “continue to experience pain, dysphoria, or nausea”, suffering that is commonly unknown to providers or families.” Several research papers support the fact that the assumption that palliative sedation eliminates suffering in all cases is false. Consider: Hans Kueng, Roman Catholicism’s best known rebel theologian, is considering capping a life of challenges to the Vatican with a final act of dissent – assisted suicide. Kueng, now 85 and suffering from Parkinson’s disease, writes in final volume of his memoirs that people have a right to “surrender” their lives to God voluntarily if illness, pain or dementia make further living unbearable.” History shows that religious institutions have got it wrong before causing human rights violations to proliferate. Religion takes too long to catch up to societal changes and has a very bad track record. Apologies are useless when offered decades later, or even a century later in some cases.
Many stories don’t make the headlines, but they are there in great numbers. There is evidence that as decades pass more and more Canadians want this individual right to doctor assisted death. Why? Technological and medical advances have not made dying easier for everyone; it is merely prolonged in many excruciating circumstances; All pain is not manageable. Families suffer too watching their loved ones suffer. There is admirable effort now to keep a person alive and as comfortable as medically possible through palliative care. That is addressing ’assisted life’. But this effort has gone too far by denying terminally ill patients who do not want to go that route to be victimized by the law as it stands now. Should the medical profession not hold dear the concept of compassion? Dr. Low did not know how soon his moment of death would come. In those 8 days he lived in high anxiety and fear of what was to come, a state that is emotional torture. This is something that new legislation with carefully thought out guidelines can help to alleviate. Give individuals their human right to choose their own ‘end of life moment’. How much longer are we going to delay? If everyone supposedly knows that ‘it’ is already happening now across the country illegally, why does the government not recognize that they are making matters worse for dying patients and their families by denying individuals the final choice they are making about their own lives? Of course, there must be great care in formation of policy. We need our politicians federally and provincially to actively engage in ’getting the ball’ rolling towards action now! Politicians have the responsibility to listen to Canadians and act to make Canada a better place to live, and yes to die. That is what we entrust them to do. Working out the details will be challenging, but please move on it. Time to give the suffering individuals their right to choose. Time to show the ultimate compassion. This issue screams for action because for many it is already too late. For many it can not happen soon enough. Medical advances and technological changes that merely keep someone breathing and suffering longer has propelled us into a new age of how we die and we have arrived at the point that people around the world, including Canadians, are demanding their human right to make their own choice.
I have been in the position of having to make the decision to remove life support, for a loved one. The physician was very understanding and informative and supported our family throughout the entire process. However, after going through this, I strongly believe that we should have the right to physician assisted suicide when care is deemed medically futile.
why do we have to prolong the suffering?
I am the widow of a physician who had Parkinson’s disease. Knowing that even with excellent treatment the prognosis was for helplessness and dementia, he ended his life while he could still die with dignity. Others facing chronic conditions should prepare clear, and witnessed, advanced care plans.
I simply find it difficult to believe that an individual cannot leave something meaningful behind after they choose to move on. With shortages in organ donations, who is really stalling quality of life for those in need?
I would prefer to choose my time and in such a way as to leave my organs to someone who wishes to live longer. Antiquated religious belief systems should not be the governing factor.
I totally agree that medics and family should follow the wishes of the patient when she/he is in a situation of futility, or when she/wishes to die – for her/his own reasons, maybe not medical.
This is why I have an Advanced Care Plan or Living Will. I don’t want any confusion or misunderstandings at the end of my life. My SDM has agreed to follow my directions regarding my end of life decisions (even if that person does not agree with my choices) I witnessed my father being kept “alive” on machines when the MD had already explained to us that most of his brain was “dead” due to a major stroke. Dad had never discussed his end of life wishes with us before he got severe dementia and Parkinson’s disease. We, his children, knew that he would never have wanted to be on machines for who knows how long until the inevitable end. He wouldn’t have wanted his life to end like that and he wouldn’t have wanted to put my mother through it either. My mother would not agree to a DNR even though there was no hope of Dad ever returning to us. Luckily, Dad didn’t last very long after we met with the MDs about his condition and Mom didn’t need to make that DNR decision. Both my sister and I would have said yes to DNR. We have learned from this experience and we all have Advanced Care Plans (including my mother) so that our lives (and or suffering) will not be prolonged unnecessarily. I actually want the legal right to Physician Assisted Suicide if I ever get to the point where my life is not worth living anymore. I do not want to be a burden to my family or the healthcare system when there is no longer any hope for me to have a fulfilled and dignified life. I hope that Canada will soon join the wiser nations who have legalized this choice.
My mother had a massive stroke aged 87 in 2000. She was permanently paralyzed one side, could not swallow or speak nor control bodily functions. When admitted to hospital, she tugged on the doctor’s white coat with her good hand until they propped her up with pen and pad and she wrote “Euthanasia”. I had her living will. I was told my only option was to remove her feeding tube and watch her starve to death over 3-5 weeks, shorter if I withheld water. This is barbaric, we treat our sick dogs better than that. We need legal assisted dying, be it by a physician or trained lay person. I don’t want to die a lingering death, be a burden on society or family, and I want my living will and Advance Care Plan respected, not overruled by a physician’s personal beliefs or hospital protocols. We need to change the law – Quebec has taken the lead.
Thank you for allowing this discussion, which is extremely important. My mother-in-law died in hospital from complication from a stroke after six months of lingering. At one point, she started pulling on her hair and grimacing to indicate to us that she was in severe pain. When we asked the physician to administer a painkiller by injection (because she could not swallow), he balked. I understand that he was afraid of giving her anything that might hasten her death. But seriously? She was 87 years old. He made my husband and his siblings sign a document indicating they understood that there may be such an outcome and to hold the physician not responsible for that eventuality. I understand that physicians face up to 14 years in prison for “hastening” death, but that is preposterous. The law and our healthcare system must get with the program and stop causing undue hardship on patients as well as allowing physicians to practice medicine as they see fit.
I would like to strongly urge the College to consider a policy of compassion towards patients who make a request for an assisted death. When a person clearly wishes to die, and has made such a request of his or her own volition, either personally or through his/her duly appointed health representative, then that person’s right to make such a decision should be respected.
I believe that a health representative should be able to make such a request for a reason – with the threat of Alzheimer’s looming as a possibility in my own life, it would be quite possible to make a request myself for an assisted death before I can no longer manage my own life only to ‘change my mind’ as the Alzheimer’s progressed. I would therefore want my health representative to be able to say, ‘no, she made her request when she was in her right mind, and that is the direction we should honour’.
While I have the utmost respect for end of life caregivers, there is nothing dignified about being an emotional and financial drain, not only on one’s immediate family but also on society in general. It truly is a waste of precious health dollars to prolong a life when the quality of that life is long gone.
I also have a lot of respect for hospice and palliative care – if, someone is lucky enough to be able to access hospice. However, for some illnesses, being kept pain free is far different from what most people envision. Seriously, take a good look at someone amped up on morphine – is that how anyone would want to end up? Confused, hallucinating and feeling all alone, even though your loved ones are right there?
It seems to me that the ‘slippery slope’ theory – which has shown itself to be non-existent in jurisdictions where assisted deaths are being permitted – is being used as a shield by people who want to control other people’s lives but cannot come up with a good reason for wanting to do so.
In my view, if someone doesn’t believe in assisted suicide, then they simply won’t ask for one; it is entirely their choice. Similarly, if a doctor doesn’t feel that he/she wants to participate in an assisted death, then that should be their choice.
But please, encourage doctors to have the courage to respect their patients’ wishes.
As the wife of a wonderful man afflicted with early onset Alzheimer’s I can say unequivocally that not all life is precious. Not by a long shot. There is nothing precious about incontinence. There is nothing precious about mushed up institutional food. There is nothing precious about being terrified of bathwater. There is nothing precious about not recognizing the children you once cherished. There is nothing precious about being unable to talk. There is nothing precious about being obviously in pain, yet unable to say what the problem is. There is nothing precious about walking miles and miles in a hospital corridor every day because your brain, for some unknown reason, compels you to get up and walk. There is absolutely nothing precious about being unable to interact with other people in any meaningful way. There is nothing precious about a life that excludes off all of the things about life that you loved – music, books, sports, good food, friends, the list goes on. Imagine a life without any of the things you love. Surely someone trapped in such a predicament should have the opportunity to end an unendurable life that brings no pleasure to them or to anyone else.
Doctors have the knowledge and ability to help their patients end their lives if that patient so chooses. Please empower doctors to follow their patients’ wishes.
I have thought about this to a great extent and discussed it with many people including family. The majority believe we should be able to choose how our life ends. I have seen many including family suffer extreme pain unnecessarily relieved somewhat with morphine. They had intravenous feeding, oxygen, and the indignity of wearing Depends etc. It is traumatising for all involved in this process. I want to make my own choice, if able, when my time comes.
Trust is a big issue for family of the patient thrust into the very necessary role of advocating for an aged parent.
The attending physician in Hospital had already dismissed our father’s ability to to recover, because he was 94, before he was even fully evaluated. Dad was fully cognicent of where he was and what was going on. The fact that he was very hard of hearing was dealt with by this physician deliberately excluding him from conversations regarding his situation and proposed care by declaring him as having “dementia”. Even though the social worker assigned to his case insisted he be present at the meeting, she faced us and talked as though our father was not even there.
We were fearful of what would happen to our father if we were to leave him alone in hospital in this situation. We took turns – shifts actually – to ensure he was not left alone too long. Our fater was not ready to die. He was still a vital human being in a frail body.
Well over a year later, when he actually did reach the point where his body was failing and he was again in hospital (a different one that the first time)we were able to speak with a wonderfully compassionate physician about end-of-life care. We were empowered to make a decision that we felt was in alignment with our father’s wishes and beliefs.
Palliative care is very difficult for the family. Even though everything is being done to ensure that the patient passes with dignity and with as little pain as possible, it is VERY hard to watch your loved one go. This Doctor and the palliative care team at that hospital supported us as well as our father in those difficult final weeks. This could/would never have been the case with that initial doctor who wrote my father off because of a number that was his age.
Seniors especially need someone to advocate for them to ensure that they are treated with compassion and dignity. The current system does little to provide that to them.
What will your system do to ensure that all patients, regardless of their age, are treated with compassion and dignity?
We humans like to have some control over our environment, our body, our lives. To have that taken away from us when we are sick and frail and unable to defend ourselves is very frightening. Individuals should have the right to choose to die, providing they have given it due consideration. We know that the dark dog of depression can temporarily cause us to wish to die. I’m not talking of that. I’m talking when the body has deteriorated to the point that life is in no way enjoyable. Then we should have the option to end it.
I listened to my Mom beg for me to help her die for 3 solid weeks while everyone thought it was important to keep her alive. What would possibly be a satisfactory reason, she could never be the person she once was, could never go to the bathroom herself or walk or breathe right or eat properly. She just wanted to die and be pain free not a big ask but it is because too many other people have a say that WE MUST SUFFER UNTIL THE LAST BIT OF BREATH IS TAKEN FROM US. LET US DIE WITH DIGNITY, if there is not help let us go back to where we came from. Because not only the dying but the living beside her feel every bit of that pain. We do not let our animals suffer why does anyone think it could possibly be humane watching a human being suffer so. ITS OUR RIGHT TO DIE IN PEACE WITH DIGNITY IN TACT.
Having worked in hospitals and nursing homes and seen people being kept alive by machines, even against the patients wishes if they are still lucid, to me is nothing more than barbaric.
Let the patient make their own decision, long before it becomes a tug of war between medical personnel and emotional family members.
Yes, we urgently need an open discussion and DOCTORS should be leading this discussion as they are the ‘experts.’ The majority of us don’t have a clue about the complex issues involved. When the public understands the issues better, they will more readily honour the doctor’s clinical judgment in a crisis.
I see death as part of life, not a treatment failure. I’m not afraid to die, but I am afraid of a prolonged process of dying. My wishes in my advance care plan should be paramount. My sons know I want to avoid prolonged suffering and hope to live well until life ends — then LET ME GO.
I believe that we should not deny the rights of those (including myself) who believe that when it is obvious that “end of life as we know it” is pending, and that other options are unavailable or not conducive to our situation for a good quality of life, then the decision should be ours to make that we find the means available to us to end our lives in a manner that will be “life-giving” (as contrary as that sounds) as possible to those we leave behind. I spent many hours sitting by the bedsides of loved ones “waiting for them to die”, unable to talk to them (because the loved ones were so doped up with morphine, etc.), unable to help them in any way, unable to convey to them how much they were loved and admired (the last words you want to be able to say to someone who is lucid moments & seconds before they take their last breath). Being able to pick the moment of death for ourselves and bringing family and friends together to say “goodbye” and to be able to tell them how much they meant to you during life, and, for family and friends having the ability to say what they wish to say to you before “Life’s sweet parting” makes life’s sweet parting so much sweeter and easier for everyone concerned. We should be able to have the choice of how we want our last moments to be! It is not only a matter of personal choice but one that will save billions of dollars in the days ahead when all we, “Baby Boomers” soon come to our end days. Can the system as it is today, handle the care and costs this would involve?
Every one of us must die. Doctors should make the process as comfortable as possible. Being technically alive is not something doctors should seek at all costs for their patients. When death is imminent and treatment may delay it for a few weeks or months please offer the alternatives of 1)comfort care, and 2) a peaceful, safe death by choice (via Nembutal).
My experience is with a parent diagnosed with stage 4 metastasized melanoma. Fortunately, there was a personal directive, but the parent was able to confirm her wishes with the attending physicians as well.
With less than 6 weeks to live, nevertheless, it was recommended that there be a surgery for one of the tumors. Afterwards, it was clear that the procedure was ineffective and simply left a wound that wouldn’t heal. Why do this, when it did not add to the quality of life for the short time left?
Further, in the last week of life, the pain experienced by the parent was almost unbearable – any movement hurt. A desire was expressed to ‘not wake up in the morning’. Surely, when there is a terminal illness and no hope remains, doctors can see that true ‘care’ would be to grant the person’s dying wish to end their suffering, rather than wait out death.
As a member of the public, I am very grateful to a doctor I have never met. When my mother was approaching the end of her life, her doctor called me to say that he believed she might have cancer. My immediate concern was that he would want to start testing and I was very relieved when he, very gently, recommended not doing anything about it because she could not benefit. She died very shortly after that conversation. I did not share that story with very many family members as I felt it would upset some of them and I didn’t want to engage in that. We are indeed a death denying society. Many of us have never seen a baby born or seen a person die and we have lost touch with reality, even to the point of refusing to take care of our own bodies while we live. Apparently many of us believe that we can smoke, drink and eat burgers all our lives, expecting some medical miracle to save us at the end. I think there is a lot of work to be done around bringing death out of the closet before we can comfortably have these end of life conversations.
I recently sat with my father, a physician, while he died at 85. Post-surgery, his slight cardiac insufficiency worsened. Once the routine drug treatment failed to alleviate or stop his worsening condition, I stopped continued blood testing as no one was going to operate on him to “fix” his stenotic valve. Surprisingly, the medical resident was very uncomfortable with my forthright attitude of not continuing futile treatment.
No feeding tube, no IV’s, just a stent for morphine when the palliative care team came in. As with my mother’s death with oat cell lung cancer, the natural dying process was allowed to unfold. (Well, except for the morphine because of the struggle to breath).
Quite frankly, I would welcome physician-assisted suicide if I were facing a slow, lingering death. Just in case I cannot make myself clear, or my SDM is not as knowledgeable about what care and comfort really means or the palliative care team is not generous with the morphine.
I would prefer that giving treatment for comfort that also hastens death come out of the shadows where family members and nurses operate, and into the light so even those who are not medically knowledgeable won’t have to suffer.
And, please don’t frame this debate about the costs; there are civilians out there who are afraid to sign a donor card in case doctors let them die just to harvest organs. I can’t see these people trusting doctors who say there is nothing to be done while one argument in the debate is that it is a waste of money. It is, but better for frame it about saving their loved ones from unnecessary pain and suffering.
I recently watched my father-in-law suffer through end stage pancreatic cancer. His last few days of “existence” consisted only of agonal breathing, while emotionally and physically exhausted family members stood by on “death watch” -waiting for the inevitable end, every passing minute an eternity. Last week, my nearly 101 year old grandmother was admitted to hospital with pneumonia (after a day spent in the ER) because there was confusion about her care directive at her nursing home. Although it has since been clarified that she is to be only “comfort care”, due to her unnecessary resuscitation, our family is once again on “death watch”. We wait for the inevitable as she moans in pain, the morphine dosage horribly inadequate. She is hardly “comfortable”, her state certainly not “dignified”. In her rare moments of lucidity, she cries out that she wants to get up- her last dying wish only to be able to have a bowel movement in the bathroom, humiliated at being forced to use a diaper for the first time. OUR SYSTEM IS BROKEN! I am ashamed to be a physician at these moments, unable to help my family at their darkest hour.
It is time for more physician’s to accept the wish of some patient’s who do not want to postpone death, when life has no quality, and be able to help them leave with dignity.
Over my lifetime I have watched at least eight terminally ill people die in pain and suffering. Due to this experience, I strongly believe in Physician assisted end of life practices, should that be the wish of the terminally ill patient.
To that end I have prepared a living will that states my end of life choice. My children, doctor, and lawyer have been provided with up-to-date copies. Should anyone in my family or my doctor, or an institution where I might be when I am terminally ill disagree with my choice, my wishes should legally take precedent over theirs.
Without a law in place allowing physician assisted end of life practice the terminally ill patient is required to consider the possibility of becoming incapacitated, and subsequently not be able to end their own life. They then must choose to commit suicide sooner than need be necessary or suffer a painful death. This is discrimination. In Canada it is legal to take your own life, but should you be incapacitated you must suffer until the end.
In taking their own life, a terminally ill patient may be unsuccessful. This could result being left in a vegetative state, causing undue grief to their family, and a burden on the medical system.
Canada should prepare a strong law giving the terminally ill patients the right to physician assisted death, if they so choose. If such a law, with teeth, was in place, more Canadians would be encouraged to obtain living wills, expressing their end of life choices and freeing up family, and medical personnel from making choices for them.
In point form, the random thoughts of a patient:
People should have the legal right to determine their end of life choices.
Canada needs a law that will allow physicians to respect this right.
It is the responsibility of an individual to communicate the manner in which they receive physician assistance at the end of life.
The physician should be required to follow a patient’s request, regardless of any objections by family or institutional policy.
Today, many die in discomfort and pain, undergoing uncomfortable, costly tests and procedures, without having been given the option of expressing the care and level of treatment that they desire, knowing their condition is terminal. This is criminal.
At this time few patients will ask a doctor to terminate their life, knowing they are asking for something that is illegal. That is why we need strong legislation that will allow physicians the right to end a terminally ill patient’s life, peacefully, if that is the wish of the patient.
Terminally ill patients left to their own means of ending their life could well complicate the conditions that exist, leaving them in a vegetative state, and a burden to their loved ones.
If the law allowed physician assisted end of life for terminally ill patients, then;
money would better be spent promoting the need for living wills.
and physician should educate their patients on the importance of obtaining a living will and keeping it updated.
Futile care is when the patient is going to die in spite of medical treatment.
All adults should be given a Living Will form at their first visit to their physician and if they fill it out put on their file.
The physician’s role should be to alleviate pain not extend life at all cost because the family can not accept the loss.
Training in medical schools should include this. Maybe they do but are they implemented?
We need to overcome our denial of death. Death does not equal failure of treatment.
We need a new standard of care for the end of life, with improved palliative, hospice and home care services.
And for those who want it and who are competent to make this decision, assisted dying should be made available through a controlled and externally monitored process. Other jurisdictions have shown that this would be safe and reduce suffering.
I have severe early-onset osteo-arthritis. My mother had it. My daughter has it. Until my daughter was diagnosed, my physicians were unable to diagnose me. I am in chronic severe neurogenic pain. I have found no effective pain relieving medication. All medical care that could be thrown at this condition is futile. I have arranged my life to accomodate the pain while still living what I consider a good life. The time may come that the pain is so overwhelming that I must conclude that my quality of life is totally eroded. At that time I wish to have the right and opportunity to make the decision to die a good death. If I am not physically able to kill myself, I wish to have a supportive physician to help me administer the life-ending medication. I most certainly would not want to be kept alive at great expense to the medical system at that time, I would consider that a futile expense.
Having read everyone’s comments here (after previously posting), I agree that the individual should have the right to determine the course of his / her dying. What scares me, what I oppose, is making it LAW that the medical community can opt to withdraw treatment / “assist” patients into death. The slippery slope we so often hear about.
Can we not somehow make a law that de-criminalizes physician-assisted suicide, while at the same time protects patients from other people (medical or lay) deciding for them? I want the right to determine the manner and timing of my own death, but don’t want to force manner / timing on others. Nor do I want the manner and timing of my dying to be determined / forced by law or social norm.
If someone’s faith or personal beliefs prohibit medically assisted death, then that should be respected. Money, scarcity of resources, financial or other “burden” on family or society, should not be the deciding factors in a person’s manner or timing of death.
I agree with the right of the individual to die as and when he / she determines. I just don’t want this “right” to grow into an obligation to “choose death.”
This is a complex issue with many facets. It is incumbent on the medical community to become very actively actively involved with giving Canadians all the facts.
Science has given us a new problem and we need to understand the costs to society in ways people can understand. We need to accept the fact there are limited health care resources. When we extend the life of a person beyond the point where they have any meaningful existence there are other medical priorities that have no funds. A family cannot be allowed to have access to almost infinite medical resources because of non science based views.
In addition there needs to be a template acceptable to both the Medical community and the legal community that allows a living person to make a binding statement on how his or her end of life is to be managed. We need to remove the threat of legal action that at present seems to cloud many end of life decisions.
Interventions that are “medically” futile might not always be worthless to a patient or family, and this distinction should be part of a “societal conversation”. For example: not withdrawing treatment on grandpa who is dying from his stroke, until an out-of-town family member can arrive in another 24 hours to say goodbye, or offering palliative chemo to a young mom who wants 3 more months with her children. Although these might be futile in a medical sense, proceeding with the treatments could provide time with the patient that the patient & family deem valuable enough to justify the intervention. Do we, as a society, want to allocate some of our resources to this kind of intervention? Framing the question in this way might help alleviate the adversarial situation of a doctor who thinks treatment is a waste of time & resources (because it is medically) and a pt/family who thinks it is not (because it provides something the pt and family value).
Euthanasia & physician assisted suicide (PAS) have been mentioned in this discussion. The phrase “dying with dignity” is often used to advocate them. If all physicians (and health care professionals) treated patients and their families with real dignity (that is to say, if we saw each person as having inherent worth and acted accordingly) it would be next-to-impossible to euthanize a fellow human being.
In 1999 a researcher at a Grand Rounds I attended reported on an anonymous survey from the Netherlands. Doctors admitted to euthanizing patients to free up hospital beds. Anyone who thinks this sort of abuse of the system would not happen in Canada is being naive.
(All doctors know there are all kinds of “abuses”- some more significant than others – within the health care system – as in every workplace setting.) And anyone who cares about dignity for others – not to mention themselves when they are eventually dying – ought to take care when advocating euthanasia/PAS.
Honesty by the doctors, who so often seem to find the subject uncomfortable to discuss with families, would be a good beginning.
Also consistency. When doctors change rotations on a weekly or biweekly basis each comes with a different approach. We need honesty and consistency.
I have outlived my sixteen-year old daughter and had to make choices I hated at the end of her life but it came down to this: prolonging life is good, prolonging death is a horrendous -even immoral- ill. If we had not been surrounded by caring and experienced end-of-life specialists who not only made this distinction clear to us but also understood it our daughters’ death would have been made even more unbearable. Physicians: do not prolonge death in the name of medicine.
A living will will solve many problems, one that may be written and copy given to hospital, doctor and lawyer. There should not be any difficulties with family because the patient has stated his wishes, if there are problems, the family does not count, the patient’s living will, or verbal orders are to be respected and followed. As one who is living to a time line, due to heart, stroke and final stages of COPD, if I could pass peacefully, before I lose to much more weight, I would seek a cocktail or needle and just fall asleep at a time of my choosing. My body, my life my choice .. your body, your life, your choice. This is not immoral, my god is a kind god and he has given mankind medicine and science to alleviate pain and suffering. My choice, and to treat a dog better when it is time to put it down shows the immorality of our system and an absence of real compassion for the ill.
If death with dignity were a legal option it would free up hospital beds and provide relief for the patient and their family. The long process of dying is far too stressful for many patients and their families and also an unnecessary waste of our medical resources. This drives up our medical costs and wait times for other patients. My sister chose to die at home with drugs to ease her pain but without surgery or chemotherapy after being diagnosed with pancreatic cancer. Her doctors supported this decision and provided support and information to the family regarding her care and what to expect as her 2 year journey continued. Luckily she had many friends and family members willing and able to ease her final months but many others do not have that option.
As a nurse with 45 years of experience I believe that it is time for everyone to have a talk with their doctor about end of life decisions. Certainly every physician should have a frank talk to patients over 60 about their future. The one day I thought I would quit being a nurse was when a 99 year old lady with gangrene fully up both legs and in multiple organ failure being put through tests and treatments while tied down begging to die. It was so futile and seemed like total abuse. I was reprimanded by the doctor for speaking to her family about it. Fortunately all the rest of the staff including some of the doctors agreed and the next day she died peacefully with all treatments removed and morphine to ease her pain. Cancer is another area where patients are not given the straight facts about their chances of survival when they undergo painful treatments and spend their last months in agony instead of taking the days they have left and living them fully. Families need to be educated as well as often it is their guilt about neglecting a parent that motivates them to push for all measures. It is in fact cruel to prolong dying instead of putting our health care resources to PROLONGING LIFE. Death is the final stage of life. Why are we afraid to embrace it when it comes.
We have had several family members who’s illnesses were treated beyond what I would personally want done for me. The extended length of some of their live were mainly made up of more doctor visits, treatments, disabilities, drugs all to no avail. There were some short times when some quality of life could be enjoyed although rare and short. Great stress is suffered by all in these situations. The docs were honest and I personally appreciated that.
#1 Yes, a societal conversation is critical right now, before these issues become overwhelming.
#2 Thankfully my remaining grandmother and parents have made their wishes clear in advance of having to make these decisions. Unfortunately there is no legal/medical framework to ensure that their wishes are respected at this time.
#3 I haven’t been in this situation, and I hope that I never will be if these issues can be addressed collaboratively, respecting the patients wishes, the relatives’ input, and the professional values that we depend on.
The organization Dying With Dignity would be a great resource for anyone trying to approach and deal with any of these issues.
More education on Medical futility could reduce peoples reluctance to make a firm decision.when its about money and lack of resources Dying with Dignety will be the in thing.
As a member of Dying With Dignity, I would like to know what proportion of family doctors in Ontario believes in a dignified death and would be prepared to help a patient to achieve this.
Thank you.
I work on Pal unit for many years. I think patient loose control over their body the moment they hear news cancer. They are forced into treatment too early. Why oncologists force to take toxic chemo without knowing themselves the cause of cancer, without giving patient time to digest the shocking news, without believing that they can cure- is beyond my comprehension. Poisonous chemo just shrink the tumor and suppress the symptoms not heal. Patient should have control and choice throughout his journey and doctor should be his guide not pusher of toxic drug
I think we people should educate yourselves when we are still healthy, to be prepared when faced with terminal illness. It will be too late to learn when sick. Cures of chronic diseases in Canada is worse year by year as the cause is never found. Children and young adults are dying of cancer. Very sad. We need strong medicine which is based on true science not on fabricated evidence and probability.
Under no circumstances would I ever agree that doctors should have the sole power over life and death. As a person living with a disability whose own doctor talks about me but never to me, whose doctor knowingly made my abusive parent my SDM and after reading through these comments in which lives like mine are described as a burden, a drain, undignified and a waste all I can say is that doctors cannot be trusted with such powers. Many patients and families do not trust Canadian doctors and all one has to do is read through these comments to see why. If you want to help people make tough choices then start treating them as people and not a burden, waste etc.
After 15 years of practice in oncology and palliative care I can only recall a few cases in which we had extreme difficulty in obtaining comfort for the patients. Terminal sedation has become embraced as a natural option for those individuals with intractable & severe symptoms and virtually no QoL. In those situations, there were no disagreements among family members. In the undergraduate medical education program at our University, we introduce the concept of a Goals of Care meeting for palliative and EOL care in the 6th week of medical school. Having these discussions early on in medical education primes students to consider this ‘standard practise’. The goal of course is to allow one to clearly document of their wishes under various possible scenarios. I fully respect that illnesses other than cancer, such as ALS, severe brain injury/death, advanced MS; provide more complicated EOL scenarios….but having this conversation early can only help ensure the patient’s wishes are expressed, documented, and eventually shared with the family members who are power of attorney (if that is desired). Increased funding for ambulatory palliative care services is needed so opportunities for discussing these important issues are frequent. There is enough evidence to support the use of ambulatory clinics to minimize hospitalizations and improve quality of life. Many communities have no such clinics.
I believe that the concept of Advance Directives should be introduced to the patients by their Family Physicians. The Family Physicians should discuss this with their patients at least every 3 years. This encourages our patients to start thinking about the Advance Directives and do research on it. Through this, the Family Physicians would be able to discuss end of life care with their patients and be able to answer their questions.
We have some objective data on the expected benefit of offering prolonged, technologically intense care based on age, comorbidities, and severity of illness. Technologically intense, invasive, and expensive healthcare where the outcome is very likely to be death regardless of what is offered should not be the standard of care. Our public healthcare system should fund evidence-based therapies where there is a reasonable hope of a good outcome As such, if patients/families want anything other than this, perhaps rather than not offering it at all, there needs to be a way they can pay supplemental premiums to OHIP or even pay out of pocket for this. As unpalatable as this may sound, sustainability of our system without jeopardizing all the other important initiatives public funds are for is paramount. This is not without precedent (NICE in UK, etc), but would require a major shift in public preception/opinion and some serious political will to accomplish.
when at least 2 independent medical experts have agreed that the treatment is futile, at that point the treatment should be considered an uninsured service and the family must become responsible for the costs, if they want to go against their advice.
It’s that simple.
Suicide has been considered a crime, and rightly so. Assisting with suicide is totally outside a physician’s defined role. We have reached the point where older people are dreading going into hospital for fear of being exterminated. If family members want to kill a relative they should not/not involve a trusted physician.
With regard to providing ineffective therapy it is within the purview of the responsible physician to decide. Responsible end-of-life care involves providing water and food and just sufficient medication to avoid excess discomfort on the part of the patient.
A person’s life is something to cherish, nurture, love and celebrate from conception to natural death. Life and the healing thereof extend not only to the physical but the emotional and spiritual. No aspect of a physicians care should put an end to life or hope. Neither should a physician be bound to do so against their will or beliefs.
FROM A RETIRED NURSE:
DIGNITY IN END OF LIFE CARE:
WHAT THEY CALL PALLIATIVE CARE IS NOT !!!
Covering Mom with Family Members visiting overlapping vigilance was crucial to managing her Pain in advocacy ..BUT ONLY EVENTUALLY.
For 3 days I was requesting better pain management:seeing & hearing Mom moaning in pain after ten minutes after a Sub Cutaneous injection WAS NOT giving her relief!!!
WHAT THEY CALL PALLIATIVE CARE..IS NOT !!!
Evidence of lack of real STAFF TRAINING for END OF LIFE CARE.
My Brother even asked the Supervisor Nurse what’s the transport System in her dehydration condition to deliver these injections?
When the Supervisor verified her chart …she said it was because it was ordered PRN (every 4 hours as needed)by the Doctor ….meaning depends on the Health Worker(not a Nurse)During Nightshifts workloads can be 40 patients .So she procured a new order NOT PRN. Mom was assessed every hour for pain status.And Family could phone at nightshift when- ever to check on her status.
Our family did not know doctors unilaterally put DNAR on our Matriarchs chart. She had become diabetic and when she became unwell sent her for cat scans of the head, neglecting the obligatory blood glucose! It is unbelievable to think ICU Doctors did not know what to do. Did they use their DNAR to get rid of her? Is there any other reason they neglected to do what anyone knows they must do when a patient is Diabetic? No Doctor should be allowed to DNR / DNAR a patient without asking a families permission, or even telling the family what they had done secretly.
The current state hasn’t effectively dealt with disagreements between treating physicians and family. Any proposed approach will have to acknowledge and deal with both parties legitimate concerns, values and feelings in order to be helpful.
AgreeGood communication is the foundation of a reasoned decision. Unfortunately, end-of-life discussions for many chronic conditions do not happen in a timely manner with the patient and the family. We must routinely incorporate these discussions along with the advance directives way ahead of time. This will facilitate the process for understanding and appreciation of medically futile interventions – i.e. prolonging the dying process. In a publically funded system, sometimes clinically unnecessary investigation and treatment are pursued without credible justification. Public dialogue around these issues with the funders and providers are crucial.
AgreeI found the Hassan Rasouli decision disappointing, not so much for what the justices actually said but how it is in danger of being misinterpreted. All they really ruled is that physicians cannot unilaterally withdraw life sustaining therapy. It is likely to be misinterpreted as a family’s blanket right to insist on futile therapy.
I would hope that any CPSO policy would strongly support the physician’s ethical and societal responsibility to discontinue futile therapy. Where families disagree, the justices have laid out a clear (if expensive and time consuming) process to resolve disputes, something that should be stressed in any CPSO policy.
There is the more challenging dilemma of the waste of health care resources generated by religious or philosophical beliefs.
AgreeThe cost of health care is unsustainable. We desparately need a societal conversation on the topic. But then we need to move on to solutions. There needs to be a cost/benefit analysis brought to all the decisions we make in health care, not just at the end of life.
AgreeOther publicly funded jurisdictions like education and the environment are suffering financially in favour of luxurious and arguably wasteful health care.
Stating discontinuation of care should be done based on “lack of improvement” is immoral and not ethical. I’m appauled at the college for such a statement! Sometimes stability is all we can achieve and may be better than worsening. Improvement may not always be achievable but to discontinue care based on lack of improvement is assine!
AgreeI start with the position that human life has an intrinsic value that warrants guarding. Suffering, while not welcomed by us, can have its own healing benefits. All people relating to an “end of life” patient or family must do so with respect & sensitivity, with special regard to the explicit and implicit wishes of the patient.
AgreeI have requested that life supports be withdrawn when there is a consensus that conscious interactive life (not to imply “normal or productive”)is no longer likely. More resources are need for hospice and related services.
Any medical ethics and legislation that will end in legalizing “physician assisted suicide” has many more social and ethical dangers than the proponents are willing to acknowledge. I do not believe that withholding treatment for the “terminally ill” is the same as assisted suicide. We must recognize that no one can stop our eventual death, nor has the right to “play God” in actively hastening death.
The need for society to discuss the allocation of limited health care resources applies to more than “end-of-life” situations.
Even with my perspective, one can never avoid all difficult choices, or avoid coming in conflict with family memebers with very diverse opinions, i.e. differing with the physician and/or amongst themselves.
I am a pediatric anesthetist, so I am more involved in this topic looking after our young patients. I am very interested with the concept of “speed” with the family. Although most patients, even very young ones, realize that their life is inevitably going to end soon, many families do not go through this process at the same pace. They need more time. Another concepts is to be discussed as well, the idea of futility in the medium term . A patient born with a major known congenital disease (eg trisomy 18) which always causes very severe development delay and many other organ dysfunction or malformations is going to die inevitably in the medium term. Families do not have this concept of the medium term. Their experience is a day to day one, as long as the baby survives the day, there is “hope” even if it gives the patient a very painful life. None of the families (even when parents are both doctors) I met had come to terms with this medium term concept. They always hoped for a miracle. As a result, some DNR orders that are signed are reversed as soon as the patient gets temporarily a little better, or if the patients gets worse and is within range of “effective” resuscitation. I do not know what is to be done in these cases, I would welcome some advice.
AgreeI do think we need to have a societal conversation about the allocation of scarce medical resources. I think this article is excellent and very well balanced. This is a very tough issue that we must talk about. It is too expensive and hard on everybody when treatment that is futile is happening. I do quite a bit of home palliative care and I find that the oncologists are doing chemo way too late in the course of the illness; sometimes within a week of the person passing. This does not allow the patient and their family to truly face the inevitable. The oncologists do not want to have those difficult chats and stop therapy even though the therapy is making them very sick.
AgreeWhen a patient is asked to give consent for a risky procedure, I think it would be prudent for the responsible physician to also obtain clear, written advanced directives from the patient/SDM, pre-operatively. It would help with cases like Mr. Hasan Rasouli. I do not know how symptomatic he was from his benign brain tumor and if surgery was the only option.
AgreeI have buried a father, a wife, a son and a grandson.That they all died young is not an evil or tragic event. It is what it is. Death is normal and natural.
AgreeI puzzle at how shallow and fearful so many in our society are and how irresponsible many are. They would expend scarse resources without any material hope of benefit on someone in their own attempt to deny our common mutual mortality, this is one root of the difficulty in moving this discourse ahead.
Until there is clarity about whether an attempt at resuscitation is required to be offered to every patient, we as physicians will create more situations where the issue of possible futility arises. We do not have a standard of care for the dying yet many physicians believe they must offer an attempt at resuscitation. By offering this, we imply that it is a reasonable alternative but we are surprised when families and patients say yes.
AgreeI think we have to be very careful with creating a policy around this issue. It has two sides.
AgreeWe should not create a policy which gives the patient an unrestricted right to demand assisted suicide while on the other hand we have to ethically decide which investigations/interventions are prolonging the dying process.
This decision should not be based on weather the medical interventions are publicly funded or not as this makes the issue murkier and I for one am not ready to play god!
Physicians should not to be put in a position where they are forced to make medical decisions according to a policy or according to patient demands, against their better judgements.
We must routinely incorporate end-of-life instructions along with the advance directives, beginning the discussion as soon as the patient and family can manage, when an illness is identified as terminal. The ongoing discussions should include the patient’s wishes on physician-assisted suicide as well as withdrawal of life-sustaining therapy. The patient’s religious or philosophical beliefs are of the utmost importance and, when stated clearly and agreed on by treating physicians, should direct action. This does not help when only family members are available, but we need to begin codification somewhere.
Extending end-of-life instructions to become part of the consent process whenever surgery or invasive investigation is proposed may make the concept less shocking and more accepted as part of normal medical care.
AgreeI agree that death should not be prolonged and I believe that the patient’s comfort during dying is paramount.
Having watched a family member die slowly in hospital of liver and renal failure and whose death was inevitable, I wondered if stopping IV hydration created suffering in them that was unnecessary. It seems to me that providing hydration during dying is part of compassionate care and should be retained when all other measures are stopped.
AgreeThey will die nonetheless either way but dehydration seems to me to inflict unnecessary discomfort during the dying process.
medical futility article was very well written. I have not been following the other articles, however I sincerely hope that end of life care does not include, physician assisted suicide. Medicine is a second career for me, and in my first career as a nurse for over 20 years, I had many experiences helping patients and families deal with death and dying. Each experience is very unique and personal, however as health care professionals it is our responsibility to both help give direction and guidance to families, as well as be realists and gatekeepers of our limited finances. As a Christian doctor I do not wish to impose my beliefs on anyone and have always supported patients and families in their difficult journeys toward death. As health care professionals our focus is on aiding the body in healing and when that is not possible, to provide expert care and advice in the death process.
Agreethanks for reading, keep up the good work
My son taught me that it takes a year for a tree to die, no matter the cause. It is this way with people too I think. Humans think of death as a moment not a process and we are very poor as health care providers at identifying the last year of life. Health care providers spend a lot of money treating conditions that mark a life coming to the end. Our research and treatment in cardiology has prevented a lot of sudden death and our reward has been watching people die a slow death by heart failure. I would never want to participate in assisted suicide but there must be some compassionate middle ground.
AgreeI liked the article’s emphasis on pondering the goal of continued care, and its likely outcomes. As a physician faced with a spouse in a locked in state years ago, I would have found a prompt, frank discussion of likely outcomes very helpful, rather than having to hunt down the statistics on the internet. Eventually, I got that discussion with his physician, and concluded that continued care was futile based on my knowledge of how this man would suffer in an inactive, non-communicative state. I’m glad that there was an effort to understand my position, that it didn’t become a legal issue, and that I was reassured that the most difficult decision of my life was ultimately a reasonable one.
AgreeIn my experience with late life care and treatment, the conversation best begins with what the patient wants. In the case of the demented patient, the focus is on what the SDM thinks the patient most likely would want. Then the recognition that decline and death are inevitable outcomes eventually. Death is a process rather than an event. The prolongation of the process is not a preservation of life but a lengthening of the misery or suffering. These concepts need to be instilled in the relatives with sensitivity to the level of their discomfort with the topic. But, none the less, frank and clear language is needed. This conversation begins as early as possible in the case of declining patient that is not responding to treatment.
AgreeAs a society we need to talk not just about what constitutes “futile” treatment, but also start thinking about ourselves, each individually, about what we might or might not want, what our own goals of care are. This applies for little questions such as when to stop or start the multitude of daily medications aimed at preventing that stroke or heart attack. It also applies to bigger questions such as resuscitation and mechanical ventilation in a variety of circumstances. One always reserves the right to change one’s mind, of course, but to start thinking about it seems important to me.
With respect to “treatment is futile.” To talk of with-holding treatment is often problematic. Anyone beginning a conversation that way might well expect to run into difficulty. Beginning by asking what are the priorities or goals of care might lead to the same conclusion (e.g., that resuscitation or mechanical ventilation might be futile) but the philosophical orientation is more patient- or family-centered rather health-care-resource-oriented.
The Rasouli case got a lot of press, and raises interesting questions, but for most of us in non-ICU settings, the challenge with resource allocation lies more routinely in determining the context of care than the content of care. i.e., hospital vs nursing home; hospital vs home; community hospital vs tertiary care centre, etc.
AgreeIn your article in the College publication MD Dialogue, vol. 9. Issue 4. 2013) you invite discussion in regards to the issue of “medical futility”. As someone who has been working in the field of Palliative Care for close to 25 years, I find this article disturbing. Also, it seems to me that several concepts are mixed together rather randomly in this article.
For example, article is inviting the members of the college to think about is “medical futility” since its main title would suggest so, yet on the first page it mentions the complex situation that arises when “the physician, the patient, or the patient’s Substitute Decision Maker (SDM) believe that treatment is futile”. I would like to point your attention to the fact that he “medical futility” and the “belief that treatment is futile” are not one and the same conceptualization. A few lines down the article introduces the issue of “prolonging death”, which again has nothing to do with the medical futility.
Also, somehow I cannot get rid of a feeling that there is an underlying agenda being put forward here. “Allocation of scarce resources in the end-of-life context” is mentioned. “Sound institutional policies” along with “misinformation” are mentioned as well. Well, in the same issue of “MD Dialogue” the fact that the College’s main mission is to serve and protect the public is mentioned more than once. Really? History has shown what happened when an infamous politician instructed physicians to make a decision, based on human deliberation, as to who with incurable illness should be granted a mercy death. Just exactly what are we looking at here? Not sure it has to do with practicing medicine. Or protecting the public.
Limiting the argument to the concept of the medical futility, it is my opinion that such concept is based on the paternalistic medicine of the past. I totally sidesteps the fact that in palliative care the scope of practice deals with much more than the strictly objective “medical” domain. Strictly speaking the “science” of medicine as practiced currently focuses on the physiology and pathology of the living organism. Most of the time it means that the objective Cartesian universe of mind-body dissociation is followed. Yet that is a philosophical concept that is more than 364 years old!
Let’s look at the Medical Futility definition as determined by the CPSO (MD Dialogue, vol. 9. Issue 4. 2013, p.350:
“treatment is generally seen as medically futile when:
• it offers no reasonable hope of recovery or improvement; or
• the patient is permanently unable to experience any benefit.”
As a palliative physician to relieve my patient’s suffering I must provide treatment that clearly will benefit my patient along the concept employed by the Medical Ethics. There always must be a benefit to the patient from what I do as a physician. By that I mean benefit along all domains of the human being, benefit to the person as a whole. Not just along the physiological/pathological domain. It sometimes involves a lot of work, work that is not necessarily captured by the billing system, work that we are not necessarily trained for as physicians to be able to do it right. It involves a lot of interpersonal work.
It is after all about the Patient. Not about us. Not about politics or bureaucracy (at this stage at least). The treatment we provide should not benefit us or other care providers. Or the system. If treatment is instituted in a premeditated way that is designed not to provide any measurable benefit to the patient that would be unethical from any angle. The treatment we provide should be along patient’s values and goals of care. We should clearly define the goals of care that the patient has. Patients should be informed about the care we are prepared to deliver and informed about the scope of our practice.
There is lots to be done when nothing else can be done. Physicians are not particularly well trained to deal with chronic illness, suffering, and incurable disease. Futility of care should not be a consideration. It may be seen as violating certain fundamental personal needs our patients have. It invites conflict and anger. It destroys the physician-patient relationship. It should not be something that anyone should be deliberating on. The College is not exempt.
Perhaps the discussion should not be about the medical futility of care. Perhaps we could talk about aligning the goals of care, treatment outcomes possibilities and probabilities, our professional recommendations, and the limits to what we can or cannot do medically within the system of delivery we are working in.
AgreeWe live in a country with scarce resources. In a public system where funds are allocated by a central site who is responsible for governing the use and allocation of scarce resources. If an epidemic were to arise and resources were very limited would we allow a patient with little chance of recovery ongoing life support when others could be dying in the emergency department? I think too many patients with chronic illnesses are not given the opportunity to consider end of life care and if talked about in an open and non-urgent manner, may help to alleviate some of the misconceptions surrounding death and dying.
AgreeIn Hong Kong, the Code of conduct is such that withdrawal of treatment if such is futile is not professional misconduct.
AgreeI am a bit confused as to why the Canadian judge would set such a precedent case which may make life difficult for doctors and relatives.
I suspect that many of the problems occur because of poor communication early in the patient-family-physician encounter. It is immensely difficult to try to regain lost ground – lost because of poorly worded or throwaway comments made in emergency or early in the ICU stay – after the relationship has been damaged. I work in palliative care and the single most important thing I can do for a family is sit down and listen to their entire story, validating their walk through the story. Only after we have done that work can we progress to talking about “how then shall we live?”. My plea to my colleagues on the very front lines would be to take a bit more time and care in wording initial pronouncements about possible outcomes.
AgreeThere is nothing unethical or immoral if end of life is necessary to alleviate suffering from terminal and incurable disease. One must remember that the patient has the right and that suffering is not only for the patient but also the family that surrounds the patient. The decision to end life must come from the patient only and the physician involved must have sound knowledge about the natural history of the illness and treatment options.
AgreeRecent example in LTC:
1. Often one or more SDM’s simply cannot accept the looming loss. Unfortunately the SDM can feel that they are making the decision (stopping HDC) that will result in death and are “being asked to play God”.
2. Ambulance attendant, with no context regarding the end-of-life dabate of the previous two weeks, looks at the patient and states “Why is this man not getting dialysis!” This sentence undoes all the work and attempts at communication over four 30-minute phone calls with this SDM
3. Phone attempts by the MRP to inform the nurses and MD who will be recieving this patient in ER are not accepted/responded to. Transfer notes are not always able to communicate the underlying issues
We need to work as a health TEAM, including all players, and treating everyone with respect, to achieve improved communication with families. It will still not be easy, and on occasion impossible (given the psychological backgrounds unique to each circimstance). But dismissive comments regarding one provider made by another serve no good purpose. On those occasions where the hospitalist has contacted me regarding transfer especially with regard to palliative patients, or has accepted my call, a more satisfying outcome is often achieved. A big time-saver in the long run.
The comments already posted illustrate that not even the physicians are in agreement regarding these issues. Communication can therefore only go so far. But thoughtfulness and courtesy along with timely discussion well in advance goes a long way. If we are not certain if such discussions have been held we should ask, and reach out to our colleagues first before assuming incompetance on the part of others.
AgreeHealthcare money is limited. Demands on healthcare dollars will increase in the future. Current rates of healthcare spending are unsustainable. Mandate advanced directives for patients when they are capable, offer them a tour of their local ICU department to understand what it means to be on life support. Place some of the financial burden of ongoing medical care on the patient/family based on their ability to pay. Increase privatization of healthcare for non-essential services to take pressure off public spending. Respect doctors judgment, authority and decisions and protect them from legal actions or answering to frivolous complaints.
AgreeEarly and frequent communication about the goals of care, with the patient and his or her family is of paramount importance….This should normally diffuse ambiguity about care near end of life.
Physicians must schedule uninterrupted time and clearly describe the possible and likely outcomes with status quo therapy vs. (gradual) withdrawal of care. Possibility and likelihood of suffering should be presented. Time must be given to address expressed concerns and ideas.
Sometime families, SD makers, need a second medical opinion before withdrawing care. This request should be understood and supported (rather than becoming defensive).
Scarcity of resources is rarely a terrific discussion to have, as it exacerbates anxiety. However, if there is another patient critically ill who requires ICU care and the vented patient is near EOL, then it is fair to present that information to the family/SDM in most cases. Normally a clear outline of the palliative care the patient will receive once extubated will help alleviate concerns of suffering.
AgreeI am an intensivist. I hope the CPSO, the CNO, and in due course hospital policies make the following changes explicit:
Agree1. “full code” is clearly spelled out not as a demand for CPR, but rather candidacy for CPR. For example, if a decapitated “full code” patient MUST receive CPR, every one of us would see this as inappropriate, but families may interpret “full code” as a promise of delivering CPR, at least briefly.
2. a physician who wishes to stop “futile” treatment could certainly be compelled in Ontario to go to the CCB as the Supreme Court implied – that is perfectly acceptable.
3. a physician who wishes not to offer “futile” treatment should be compelled to go through some reasonable steps (for example, communicate the decision to the family, get a second opinion, consult with facility policy if applicable, seek another provider willing to provide “futile” treatment). Once these steps are undertaken, all the regulatory agencies should explicitly endorse this stance in Ontario.
The term ‘medical futility’ is frought with danger.What is considered futile today may be considered non futile tomorrow.In acute cases it is extreamly dangerous.Ex. non breathing person {hyperglycaemia}Even in chronic cases who is to decide treatment is futile? If it is too expensive to carry on it is honest to say so rather than hide under the cloak of ‘medically futile’
AgreeAs a longtime member of Dying with Dignity, I would like to have the option of a quick and painless death provided by a doctor when ‘my time comes’. I am very supportive of the current move to make this legal in Quebec. We need the same action in Ontario.
I am currently a healthy senior citizen and this issue is extremely important to me.
AgreeMy mother was diagnosed with a glioblastoma multiforme, and did not meet the criteria for treatment. The doctors in presented all the information to her in such a way that she was actually able to choose not to be treated without them actually telling her that they would not treat her. I thought it was very gracious of them. I will forever appreciate that.
AgreeI firmly believe that the individual should have the right to choose death with dignity. I for one would hate to be stewing in my own mess – a burden to a health care system already taxed to the gills – a burden on my family emotionally and financially when there is no hope for my recovery.
AgreeMy sister died at age 45 after an initial late diagnosis of metastasized breast cancer. She received palliative care at home but endured many days of pain which could not be alleviated without the quantity of morphine which would have endangered her life and was for that reason withheld. She had been diagnosed with terminal cancer. What conceivable purpose did it serve to force her to endure a final agony which could have been avoided. I believe in end of life decisions made in conjunction with medical diagnosis and allevation of needless suffering.
AgreeLeaving people dying in Long Term Care Facilities which do not have the man power or the knowledge on how to care for them is cruelty, we need to address this and have a safety net for those persons who do not want to suffer this indignity. If a person has requested to allowed to die as an alternative to living this way I think that is their individual right to do so and to be given help with dying if that is their wish. We need more discussion on this issue.
AgreeI live in British Columbia and believe that it should be discussion between patient, family, and primary family physician. I feel if a patient is terminal or has severe chronic condition such as ALS, they should be able to make the decision to end their life. And that it should be done with dignity, respect, and on the patients terms.
AgreeI have watched too many friends and family members end up in Palliative Care and their is no dignity there, they try, but it is institutional. I feel when the patient is ready they should be able to go to bed and take a bigger dose of morphine and just go to sleep peacefully and quietly.
I believe that Euthanasia and Assisted Suicide should be a part of the continuum of care, especially in situations of medical futility. It makes little sense to attempt to force a situation to be prolonged unnecessarily in a way that costs both the patient and the health care system.
AgreeWhen quality of life is nonexistent and the patient has left directives to discontinue care.
AgreeThank you all for your careful and considered responses . I have been an I.C.U. /E.R. nurse for 40 years .What I have learned is that it is really all about communication . In the current system patients and families as well as health care providers suffer often as a result of confusing “caring” with “curing”. We do not ever cure anyone of “death” ,trite as that may sound ,but we must always seek to get at the heart of “what the patient wants” and do our utmost to provide that. Legislators , politicians , and those in their ivory towers must and will eventually be forced to respond , make some difficult choices . As healthcare providers , our choice is clear . We must continue to advocate for each patient individually , especially when their choices would not be our choices .We are not the “gate-keepers ” nor “the angels of mercy” we are simply people who care .
AgreeI have given clear instructions to my next of kin about end of life issues and I would want any decision to terminate care, given by my legal representative obeyed.
AgreeA decision is long over due. I and only I have the right to decide when to end my life…..not the government or my physician.
AgreeMy son was admitted hospital in 2004. He was dealing with a neuro-disability that had not been diagnosed specifically. He was ambulatory at the time, but deteriorated quickly. He, although nonverbal, turned down tubal feeding. There was no indication that the hospital staff felt there was any hope. He was alert and able to signal to me. We had him transferred to Palliative Care. At no time was intervention suggested and within two weeks he died. He was 37 years old. No heroic efforts to save a young man who was relatively healthy a month prior to admittance. I am still stunned at how easy it appeared to be to allow this man to die. I have conflicting emotions and guilt as to whether I did all I could for him. I had a strong feeling that an accident had occurred in the hospital that he could not convey due to being mute.
AgreeOver 150 years ago, John Stuart Mill summarized the essence of the debate in one sentence: “Over himself, over his own body and mind, the individual is sovereign.”
AgreeMy husband was diagnosed with prostate cancer and underwent chemotherapy and radiation. His cancer was the severe variety and eventually moved into the bones. He had made it clear that he wanted to die. Our doctor said he could do nothing. However when my husband was in the hospital having had a brain clot, and was on morphine but still suffered humiliation (he was a retired naval officer and commercial beekeeper)and in pain, our family doctor agreed he could stop the warfarin. He died due to a massive brain clot. His children and I rejoiced that he was free. He was 72 years old and had enjoyed a full, active and enriched life. We are forever indebted to the doctor.
AgreeI am very much in favor of end of life assistance. I think dying is as much a part of our health care as being born. When the chance of a normal life is futile, then we should let them go. At 92 my sister last year was in this position, ready to go, after a stroke and heart attack, and she had to live for 2 – 3 more uncomfortable weeks. She should have been able to have a needle to end her life with all of us standing around her singing and telling how much we love her. Some of us are not afraid to die. And, the words “Assisted Suicide” should never be used again with regard to end of life care. I hope that you will do everything in your power to have this changed. Maybe the Hipocratic Oath has to be changed to give the doctors the authority to do this. Don’t know how that works. Thank you for anything you can do to make this change in Canada soon.
AgreeI realize that this discussion is taking place on the CPSO website, but does anyone but me think it telling that virtually all respondents (except “Anonymous” and myself) are physicians? Why isn’t anyone talking to and listening to us, the families of patients? Or potential patients ourselves?
I remember a home care nurse being very angry with me for not authorizing my mother’s immediate move to hospital when the NURSE thought she should be going there, despite my mother’s very clearly and frequently expressed wish to die at home when the time came for her to die. I supported my mother’s end-of-life decision. No one supported me.
It seems that families are supported only when the families agree with the medical community’s views.
We were denied at-home palliative care in my mother’s last days and weeks. “Didn’t meet the criteria” — whatever that means. I guess just being near-death, and in pain from bedsores, inability to eat, etc. isn’t enough for someone to be considered palliative. I therefore have my concerns for when I get to the stage where I will need hospice / palliative care. If I can’t be sure I can end my life relatively pain-free, then I want the right to end it when and how I choose. I’ll find a way to do that, physician-assisted or not.
All that aside, I’d like a clarification of the statement “suffering … can have its own healing benefits” (Physician comment Jan 20). Healing benefits for whom? The family forced to watch the suffering? The patient who suffers into death, with little or no medical support? What are the “healing benefits” of suffering?
The medical community talks about the need for communication with patient and/or family. So far, I haven’t seen it happening. The experts are talking to the experts, with no one yet noticing that the rest of us are even in the room.
I agree with those who say this discussion needs to be opened up to everyone, and needs to be had earlier in the game. The question re end-of-life care should not come at the end, when patient and family are emotionally stretched. And any decisions re policy should involve discussion with, and LISTENING TO, family and patient, not just doctors.
So far, we don’t seem to matter.
AgreeMy greatest fear is that I will be kept on tubes and machines against my will at the end of my life. I will do anything to avoid this. But please do not force me into the role of desperate dying senior.
Allow me the dignity of choosing the time, manner & place of my own death. It’s my life, and it’s my death.
AgreeI am a relatively young patient with terminal recurrent ovarian cancer. The only thing worse dealing with than my prognosis is the knowledge that I can not legally opt out of the paiful, degrading and hopeless living with late stage disease. I am neither demented nor suicidal. Yes, I signed DNR form and advanced directive; I can refuse food and drink. I need a better option to end my life when I chose to do so than messing with inert gases or smuggling barbiturates across the Mexican border. And I expect our politically-correct society to make this option available to me and to countless others sooner rather than later. And save a ton of money on palliative care in the process. Peace y’all.
AgreeYour body is nearly paralyzed and your lungs are slowly shutting down. You face weeks of agonizing physical and psychological pain as you slowly suffocate to death. Because of the risk of 14 years in prison, no one, not even a willing doctor, will help you to die. No one will help you even though you are a competent adult, who is fully informed about your condition and who voluntarily consents to someone assisting you to die. No one will help you even though you have a living will that states what you do not want to continue to live in this condition. No one will help you even though you have stated you want to die many times to doctors, your family and friends. No one will help even though you are not clinically depressed, but do not want to live in this horrifying condition. In Canada it is legal to take your own life, but if you are disabled or incapacitated, no one will help you to die. The overwhelming major of Canadians believe this situation should be changed. Do you?
Surveys shows that Canadians of all political parties overwhelmingly support assisted death and yet parliamentarians overwhelmingly do not. Do your elected representatives represent your needs?
Ideologues, zealots and religious fundamentalists do not support assisted death under any circumstances. Should these people determine how you die?
Who decides when to end your life if you are disabled or incapacitated: the government, bureaucrats, medical personnel, religious organizations? In a diverse country like Canada, should competent and informed individuals voluntarily decide for themselves?
Taking your own life is legal, but assisting another who disabled or incapacitated is not legal, even when that person is in intractable pain and wants to die and is competent, full informed and voluntarily consents. Does this situation discriminate unjustly against the disabled and incapacitated?
Where assisted death is allowed and adequately legislated and enforced, the disabled and incapacitated are less likely to have their lives ended illegally. Should Canada provide this protection to Canadians who are disabled or incapacitated?
Some people worry about slippery slopes (i.e., that any move towards assisted death will cause disastrous results) if Canada allows assisted death. However, evidence from other jurisdictions demonstrates that slippery slopes can be avoided with adequate legislation and enforcement. Should Canada allow assisted death with adequate legislation and enforcement?
Palliative care and pain doctors state there are situations where pain cannot be controlled. Should people be forced to endure agonizing pain or should they be able to decide when to end their lives?
We can prolong death and force people to endure excruciating pain with no quality of life, but wouldn’t it be better if the dying made their own end of life decisions?
AgreeGreetings,
AgreeI am writing in support of the principle of dignity in death.
My mother was living alone at the age of 82 years after my father’s death. One day, she suffered a stroke and heart attack simultaneously. My brother found her, hours later, on the floor of her living room. He called 911 of course, and she was taken to hospital. When I went to see her, I saw how damaged she was, and went into the hospital corridor to speak to the first nurse I saw, demanding that she not employ any heroic measures to keep my mother alive. It was futile. Mother developed pneumonia, which would have led to her death if left untreated, but they gave her antibiotics. She was later transferred to a nursing home, where she suffered for 4 long years, unable to feed herself, or speak, or use the bathroom,or get out of bed. She COULD utter the words, “Oh dear! Oh dear!” endlessly. She could also sing with us if we sang hymns by her bed. It was such an unnecessary purgatory for her to be trapped in. She did not deserve such suffering. I lend my full support to the notion that doctors should be allowed to, and willing to, hasten death for people who wish it, people who have no hope of recovery, and people for whom life is an intolerable burden.
Thanks for registering my opinion.
The medical team’s perception of futility should be given major weight because of their expertise but mstly because their opinion is more llikelly to be objective.
The emphasis should be on consideration of outcome – will the patient be better off as result of continued futile treatment?
I had personal experience in connection with the death of my father when one member of the family, who was the legal SDM, insisted that treatment continue. The result was two weeks of agonized dying.
AgreeWhen and if I become mentally or physically disabled I want to be in control what is being done to. I don’t ever want to into a home where you spend what’s left of your in God’s waiting room. It costs the taxpayer money that should be spent on other things and makes it so hard on the family (I know).I want assisted suicide to be in place. It’s already there except for the law. My mother suffered for years before going to a home where they took her off meds and gave her morphine to end her life. The problem was it took six years to finally make that happen.
AgreeSome would argue that it is acceptable to just let someone commit suicide on their own as it is now when they want to avoid end of life suffering. It is not possible for some to ‘commit suicide’ when they have reached a point of choosing death. That is what the Sue Rodriguez case was all about. Refusing treatment also does not work. That is what Margaret Bentley’s case is/was all about. Palliative Sedation? “Palliative Sedation: It’s Not a Panacea”. American Journal of Bioethics. June 2011. Within that paper: “While the intent of palliative sedation is to eliminate pain and suffering, a significant minority of patients “continue to experience pain, dysphoria, or nausea”, suffering that is commonly unknown to providers or families.” Several research papers support the fact that the assumption that palliative sedation eliminates suffering in all cases is false. Consider: Hans Kueng, Roman Catholicism’s best known rebel theologian, is considering capping a life of challenges to the Vatican with a final act of dissent – assisted suicide. Kueng, now 85 and suffering from Parkinson’s disease, writes in final volume of his memoirs that people have a right to “surrender” their lives to God voluntarily if illness, pain or dementia make further living unbearable.” History shows that religious institutions have got it wrong before causing human rights violations to proliferate. Religion takes too long to catch up to societal changes and has a very bad track record. Apologies are useless when offered decades later, or even a century later in some cases.
Many stories don’t make the headlines, but they are there in great numbers. There is evidence that as decades pass more and more Canadians want this individual right to doctor assisted death. Why? Technological and medical advances have not made dying easier for everyone; it is merely prolonged in many excruciating circumstances; All pain is not manageable. Families suffer too watching their loved ones suffer. There is admirable effort now to keep a person alive and as comfortable as medically possible through palliative care. That is addressing ’assisted life’. But this effort has gone too far by denying terminally ill patients who do not want to go that route to be victimized by the law as it stands now. Should the medical profession not hold dear the concept of compassion? Dr. Low did not know how soon his moment of death would come. In those 8 days he lived in high anxiety and fear of what was to come, a state that is emotional torture. This is something that new legislation with carefully thought out guidelines can help to alleviate. Give individuals their human right to choose their own ‘end of life moment’. How much longer are we going to delay? If everyone supposedly knows that ‘it’ is already happening now across the country illegally, why does the government not recognize that they are making matters worse for dying patients and their families by denying individuals the final choice they are making about their own lives? Of course, there must be great care in formation of policy. We need our politicians federally and provincially to actively engage in ’getting the ball’ rolling towards action now! Politicians have the responsibility to listen to Canadians and act to make Canada a better place to live, and yes to die. That is what we entrust them to do. Working out the details will be challenging, but please move on it. Time to give the suffering individuals their right to choose. Time to show the ultimate compassion. This issue screams for action because for many it is already too late. For many it can not happen soon enough. Medical advances and technological changes that merely keep someone breathing and suffering longer has propelled us into a new age of how we die and we have arrived at the point that people around the world, including Canadians, are demanding their human right to make their own choice.
AgreeI have been in the position of having to make the decision to remove life support, for a loved one. The physician was very understanding and informative and supported our family throughout the entire process. However, after going through this, I strongly believe that we should have the right to physician assisted suicide when care is deemed medically futile.
Agreewhy do we have to prolong the suffering?
I am the widow of a physician who had Parkinson’s disease. Knowing that even with excellent treatment the prognosis was for helplessness and dementia, he ended his life while he could still die with dignity. Others facing chronic conditions should prepare clear, and witnessed, advanced care plans.
AgreeI simply find it difficult to believe that an individual cannot leave something meaningful behind after they choose to move on. With shortages in organ donations, who is really stalling quality of life for those in need?
AgreeI would prefer to choose my time and in such a way as to leave my organs to someone who wishes to live longer. Antiquated religious belief systems should not be the governing factor.
I totally agree that medics and family should follow the wishes of the patient when she/he is in a situation of futility, or when she/wishes to die – for her/his own reasons, maybe not medical.
AgreeThis is why I have an Advanced Care Plan or Living Will. I don’t want any confusion or misunderstandings at the end of my life. My SDM has agreed to follow my directions regarding my end of life decisions (even if that person does not agree with my choices) I witnessed my father being kept “alive” on machines when the MD had already explained to us that most of his brain was “dead” due to a major stroke. Dad had never discussed his end of life wishes with us before he got severe dementia and Parkinson’s disease. We, his children, knew that he would never have wanted to be on machines for who knows how long until the inevitable end. He wouldn’t have wanted his life to end like that and he wouldn’t have wanted to put my mother through it either. My mother would not agree to a DNR even though there was no hope of Dad ever returning to us. Luckily, Dad didn’t last very long after we met with the MDs about his condition and Mom didn’t need to make that DNR decision. Both my sister and I would have said yes to DNR. We have learned from this experience and we all have Advanced Care Plans (including my mother) so that our lives (and or suffering) will not be prolonged unnecessarily. I actually want the legal right to Physician Assisted Suicide if I ever get to the point where my life is not worth living anymore. I do not want to be a burden to my family or the healthcare system when there is no longer any hope for me to have a fulfilled and dignified life. I hope that Canada will soon join the wiser nations who have legalized this choice.
AgreeMy mother had a massive stroke aged 87 in 2000. She was permanently paralyzed one side, could not swallow or speak nor control bodily functions. When admitted to hospital, she tugged on the doctor’s white coat with her good hand until they propped her up with pen and pad and she wrote “Euthanasia”. I had her living will. I was told my only option was to remove her feeding tube and watch her starve to death over 3-5 weeks, shorter if I withheld water. This is barbaric, we treat our sick dogs better than that. We need legal assisted dying, be it by a physician or trained lay person. I don’t want to die a lingering death, be a burden on society or family, and I want my living will and Advance Care Plan respected, not overruled by a physician’s personal beliefs or hospital protocols. We need to change the law – Quebec has taken the lead.
AgreeThank you for allowing this discussion, which is extremely important. My mother-in-law died in hospital from complication from a stroke after six months of lingering. At one point, she started pulling on her hair and grimacing to indicate to us that she was in severe pain. When we asked the physician to administer a painkiller by injection (because she could not swallow), he balked. I understand that he was afraid of giving her anything that might hasten her death. But seriously? She was 87 years old. He made my husband and his siblings sign a document indicating they understood that there may be such an outcome and to hold the physician not responsible for that eventuality. I understand that physicians face up to 14 years in prison for “hastening” death, but that is preposterous. The law and our healthcare system must get with the program and stop causing undue hardship on patients as well as allowing physicians to practice medicine as they see fit.
AgreeI would like to strongly urge the College to consider a policy of compassion towards patients who make a request for an assisted death. When a person clearly wishes to die, and has made such a request of his or her own volition, either personally or through his/her duly appointed health representative, then that person’s right to make such a decision should be respected.
I believe that a health representative should be able to make such a request for a reason – with the threat of Alzheimer’s looming as a possibility in my own life, it would be quite possible to make a request myself for an assisted death before I can no longer manage my own life only to ‘change my mind’ as the Alzheimer’s progressed. I would therefore want my health representative to be able to say, ‘no, she made her request when she was in her right mind, and that is the direction we should honour’.
While I have the utmost respect for end of life caregivers, there is nothing dignified about being an emotional and financial drain, not only on one’s immediate family but also on society in general. It truly is a waste of precious health dollars to prolong a life when the quality of that life is long gone.
I also have a lot of respect for hospice and palliative care – if, someone is lucky enough to be able to access hospice. However, for some illnesses, being kept pain free is far different from what most people envision. Seriously, take a good look at someone amped up on morphine – is that how anyone would want to end up? Confused, hallucinating and feeling all alone, even though your loved ones are right there?
It seems to me that the ‘slippery slope’ theory – which has shown itself to be non-existent in jurisdictions where assisted deaths are being permitted – is being used as a shield by people who want to control other people’s lives but cannot come up with a good reason for wanting to do so.
In my view, if someone doesn’t believe in assisted suicide, then they simply won’t ask for one; it is entirely their choice. Similarly, if a doctor doesn’t feel that he/she wants to participate in an assisted death, then that should be their choice.
But please, encourage doctors to have the courage to respect their patients’ wishes.
As the wife of a wonderful man afflicted with early onset Alzheimer’s I can say unequivocally that not all life is precious. Not by a long shot. There is nothing precious about incontinence. There is nothing precious about mushed up institutional food. There is nothing precious about being terrified of bathwater. There is nothing precious about not recognizing the children you once cherished. There is nothing precious about being unable to talk. There is nothing precious about being obviously in pain, yet unable to say what the problem is. There is nothing precious about walking miles and miles in a hospital corridor every day because your brain, for some unknown reason, compels you to get up and walk. There is absolutely nothing precious about being unable to interact with other people in any meaningful way. There is nothing precious about a life that excludes off all of the things about life that you loved – music, books, sports, good food, friends, the list goes on. Imagine a life without any of the things you love. Surely someone trapped in such a predicament should have the opportunity to end an unendurable life that brings no pleasure to them or to anyone else.
Doctors have the knowledge and ability to help their patients end their lives if that patient so chooses. Please empower doctors to follow their patients’ wishes.
Originally posted at: http://www.dyingwithdignity.ca/2014/01/31/tell-the-doctors-what-you-think-about-futile-treatment-at-the-end-of-life.php
AgreeReproduced here at request of author.
I have thought about this to a great extent and discussed it with many people including family. The majority believe we should be able to choose how our life ends. I have seen many including family suffer extreme pain unnecessarily relieved somewhat with morphine. They had intravenous feeding, oxygen, and the indignity of wearing Depends etc. It is traumatising for all involved in this process. I want to make my own choice, if able, when my time comes.
AgreeTrust is a big issue for family of the patient thrust into the very necessary role of advocating for an aged parent.
The attending physician in Hospital had already dismissed our father’s ability to to recover, because he was 94, before he was even fully evaluated. Dad was fully cognicent of where he was and what was going on. The fact that he was very hard of hearing was dealt with by this physician deliberately excluding him from conversations regarding his situation and proposed care by declaring him as having “dementia”. Even though the social worker assigned to his case insisted he be present at the meeting, she faced us and talked as though our father was not even there.
We were fearful of what would happen to our father if we were to leave him alone in hospital in this situation. We took turns – shifts actually – to ensure he was not left alone too long. Our fater was not ready to die. He was still a vital human being in a frail body.
Well over a year later, when he actually did reach the point where his body was failing and he was again in hospital (a different one that the first time)we were able to speak with a wonderfully compassionate physician about end-of-life care. We were empowered to make a decision that we felt was in alignment with our father’s wishes and beliefs.
Palliative care is very difficult for the family. Even though everything is being done to ensure that the patient passes with dignity and with as little pain as possible, it is VERY hard to watch your loved one go. This Doctor and the palliative care team at that hospital supported us as well as our father in those difficult final weeks. This could/would never have been the case with that initial doctor who wrote my father off because of a number that was his age.
Seniors especially need someone to advocate for them to ensure that they are treated with compassion and dignity. The current system does little to provide that to them.
What will your system do to ensure that all patients, regardless of their age, are treated with compassion and dignity?
AgreeWe humans like to have some control over our environment, our body, our lives. To have that taken away from us when we are sick and frail and unable to defend ourselves is very frightening. Individuals should have the right to choose to die, providing they have given it due consideration. We know that the dark dog of depression can temporarily cause us to wish to die. I’m not talking of that. I’m talking when the body has deteriorated to the point that life is in no way enjoyable. Then we should have the option to end it.
AgreeI listened to my Mom beg for me to help her die for 3 solid weeks while everyone thought it was important to keep her alive. What would possibly be a satisfactory reason, she could never be the person she once was, could never go to the bathroom herself or walk or breathe right or eat properly. She just wanted to die and be pain free not a big ask but it is because too many other people have a say that WE MUST SUFFER UNTIL THE LAST BIT OF BREATH IS TAKEN FROM US. LET US DIE WITH DIGNITY, if there is not help let us go back to where we came from. Because not only the dying but the living beside her feel every bit of that pain. We do not let our animals suffer why does anyone think it could possibly be humane watching a human being suffer so. ITS OUR RIGHT TO DIE IN PEACE WITH DIGNITY IN TACT.
AgreeHaving worked in hospitals and nursing homes and seen people being kept alive by machines, even against the patients wishes if they are still lucid, to me is nothing more than barbaric.
Let the patient make their own decision, long before it becomes a tug of war between medical personnel and emotional family members.
AgreeYes, we urgently need an open discussion and DOCTORS should be leading this discussion as they are the ‘experts.’ The majority of us don’t have a clue about the complex issues involved. When the public understands the issues better, they will more readily honour the doctor’s clinical judgment in a crisis.
I see death as part of life, not a treatment failure. I’m not afraid to die, but I am afraid of a prolonged process of dying. My wishes in my advance care plan should be paramount. My sons know I want to avoid prolonged suffering and hope to live well until life ends — then LET ME GO.
AgreeI believe that we should not deny the rights of those (including myself) who believe that when it is obvious that “end of life as we know it” is pending, and that other options are unavailable or not conducive to our situation for a good quality of life, then the decision should be ours to make that we find the means available to us to end our lives in a manner that will be “life-giving” (as contrary as that sounds) as possible to those we leave behind. I spent many hours sitting by the bedsides of loved ones “waiting for them to die”, unable to talk to them (because the loved ones were so doped up with morphine, etc.), unable to help them in any way, unable to convey to them how much they were loved and admired (the last words you want to be able to say to someone who is lucid moments & seconds before they take their last breath). Being able to pick the moment of death for ourselves and bringing family and friends together to say “goodbye” and to be able to tell them how much they meant to you during life, and, for family and friends having the ability to say what they wish to say to you before “Life’s sweet parting” makes life’s sweet parting so much sweeter and easier for everyone concerned. We should be able to have the choice of how we want our last moments to be! It is not only a matter of personal choice but one that will save billions of dollars in the days ahead when all we, “Baby Boomers” soon come to our end days. Can the system as it is today, handle the care and costs this would involve?
AgreeEvery one of us must die. Doctors should make the process as comfortable as possible. Being technically alive is not something doctors should seek at all costs for their patients. When death is imminent and treatment may delay it for a few weeks or months please offer the alternatives of 1)comfort care, and 2) a peaceful, safe death by choice (via Nembutal).
AgreeMy experience is with a parent diagnosed with stage 4 metastasized melanoma. Fortunately, there was a personal directive, but the parent was able to confirm her wishes with the attending physicians as well.
With less than 6 weeks to live, nevertheless, it was recommended that there be a surgery for one of the tumors. Afterwards, it was clear that the procedure was ineffective and simply left a wound that wouldn’t heal. Why do this, when it did not add to the quality of life for the short time left?
Further, in the last week of life, the pain experienced by the parent was almost unbearable – any movement hurt. A desire was expressed to ‘not wake up in the morning’. Surely, when there is a terminal illness and no hope remains, doctors can see that true ‘care’ would be to grant the person’s dying wish to end their suffering, rather than wait out death.
AgreeAs a member of the public, I am very grateful to a doctor I have never met. When my mother was approaching the end of her life, her doctor called me to say that he believed she might have cancer. My immediate concern was that he would want to start testing and I was very relieved when he, very gently, recommended not doing anything about it because she could not benefit. She died very shortly after that conversation. I did not share that story with very many family members as I felt it would upset some of them and I didn’t want to engage in that. We are indeed a death denying society. Many of us have never seen a baby born or seen a person die and we have lost touch with reality, even to the point of refusing to take care of our own bodies while we live. Apparently many of us believe that we can smoke, drink and eat burgers all our lives, expecting some medical miracle to save us at the end. I think there is a lot of work to be done around bringing death out of the closet before we can comfortably have these end of life conversations.
AgreeI recently sat with my father, a physician, while he died at 85. Post-surgery, his slight cardiac insufficiency worsened. Once the routine drug treatment failed to alleviate or stop his worsening condition, I stopped continued blood testing as no one was going to operate on him to “fix” his stenotic valve. Surprisingly, the medical resident was very uncomfortable with my forthright attitude of not continuing futile treatment.
No feeding tube, no IV’s, just a stent for morphine when the palliative care team came in. As with my mother’s death with oat cell lung cancer, the natural dying process was allowed to unfold. (Well, except for the morphine because of the struggle to breath).
Quite frankly, I would welcome physician-assisted suicide if I were facing a slow, lingering death. Just in case I cannot make myself clear, or my SDM is not as knowledgeable about what care and comfort really means or the palliative care team is not generous with the morphine.
I would prefer that giving treatment for comfort that also hastens death come out of the shadows where family members and nurses operate, and into the light so even those who are not medically knowledgeable won’t have to suffer.
And, please don’t frame this debate about the costs; there are civilians out there who are afraid to sign a donor card in case doctors let them die just to harvest organs. I can’t see these people trusting doctors who say there is nothing to be done while one argument in the debate is that it is a waste of money. It is, but better for frame it about saving their loved ones from unnecessary pain and suffering.
AgreeI recently watched my father-in-law suffer through end stage pancreatic cancer. His last few days of “existence” consisted only of agonal breathing, while emotionally and physically exhausted family members stood by on “death watch” -waiting for the inevitable end, every passing minute an eternity. Last week, my nearly 101 year old grandmother was admitted to hospital with pneumonia (after a day spent in the ER) because there was confusion about her care directive at her nursing home. Although it has since been clarified that she is to be only “comfort care”, due to her unnecessary resuscitation, our family is once again on “death watch”. We wait for the inevitable as she moans in pain, the morphine dosage horribly inadequate. She is hardly “comfortable”, her state certainly not “dignified”. In her rare moments of lucidity, she cries out that she wants to get up- her last dying wish only to be able to have a bowel movement in the bathroom, humiliated at being forced to use a diaper for the first time. OUR SYSTEM IS BROKEN! I am ashamed to be a physician at these moments, unable to help my family at their darkest hour.
AgreeIt is time for more physician’s to accept the wish of some patient’s who do not want to postpone death, when life has no quality, and be able to help them leave with dignity.
AgreeOver my lifetime I have watched at least eight terminally ill people die in pain and suffering. Due to this experience, I strongly believe in Physician assisted end of life practices, should that be the wish of the terminally ill patient.
AgreeTo that end I have prepared a living will that states my end of life choice. My children, doctor, and lawyer have been provided with up-to-date copies. Should anyone in my family or my doctor, or an institution where I might be when I am terminally ill disagree with my choice, my wishes should legally take precedent over theirs.
Without a law in place allowing physician assisted end of life practice the terminally ill patient is required to consider the possibility of becoming incapacitated, and subsequently not be able to end their own life. They then must choose to commit suicide sooner than need be necessary or suffer a painful death. This is discrimination. In Canada it is legal to take your own life, but should you be incapacitated you must suffer until the end.
In taking their own life, a terminally ill patient may be unsuccessful. This could result being left in a vegetative state, causing undue grief to their family, and a burden on the medical system.
Canada should prepare a strong law giving the terminally ill patients the right to physician assisted death, if they so choose. If such a law, with teeth, was in place, more Canadians would be encouraged to obtain living wills, expressing their end of life choices and freeing up family, and medical personnel from making choices for them.
In point form, the random thoughts of a patient:
AgreePeople should have the legal right to determine their end of life choices.
Canada needs a law that will allow physicians to respect this right.
It is the responsibility of an individual to communicate the manner in which they receive physician assistance at the end of life.
The physician should be required to follow a patient’s request, regardless of any objections by family or institutional policy.
Today, many die in discomfort and pain, undergoing uncomfortable, costly tests and procedures, without having been given the option of expressing the care and level of treatment that they desire, knowing their condition is terminal. This is criminal.
At this time few patients will ask a doctor to terminate their life, knowing they are asking for something that is illegal. That is why we need strong legislation that will allow physicians the right to end a terminally ill patient’s life, peacefully, if that is the wish of the patient.
Terminally ill patients left to their own means of ending their life could well complicate the conditions that exist, leaving them in a vegetative state, and a burden to their loved ones.
If the law allowed physician assisted end of life for terminally ill patients, then;
money would better be spent promoting the need for living wills.
and physician should educate their patients on the importance of obtaining a living will and keeping it updated.
Futile care is when the patient is going to die in spite of medical treatment.
AgreeAll adults should be given a Living Will form at their first visit to their physician and if they fill it out put on their file.
The physician’s role should be to alleviate pain not extend life at all cost because the family can not accept the loss.
Training in medical schools should include this. Maybe they do but are they implemented?
We need to overcome our denial of death. Death does not equal failure of treatment.
AgreeWe need a new standard of care for the end of life, with improved palliative, hospice and home care services.
And for those who want it and who are competent to make this decision, assisted dying should be made available through a controlled and externally monitored process. Other jurisdictions have shown that this would be safe and reduce suffering.
I have severe early-onset osteo-arthritis. My mother had it. My daughter has it. Until my daughter was diagnosed, my physicians were unable to diagnose me. I am in chronic severe neurogenic pain. I have found no effective pain relieving medication. All medical care that could be thrown at this condition is futile. I have arranged my life to accomodate the pain while still living what I consider a good life. The time may come that the pain is so overwhelming that I must conclude that my quality of life is totally eroded. At that time I wish to have the right and opportunity to make the decision to die a good death. If I am not physically able to kill myself, I wish to have a supportive physician to help me administer the life-ending medication. I most certainly would not want to be kept alive at great expense to the medical system at that time, I would consider that a futile expense.
AgreeHaving read everyone’s comments here (after previously posting), I agree that the individual should have the right to determine the course of his / her dying. What scares me, what I oppose, is making it LAW that the medical community can opt to withdraw treatment / “assist” patients into death. The slippery slope we so often hear about.
Can we not somehow make a law that de-criminalizes physician-assisted suicide, while at the same time protects patients from other people (medical or lay) deciding for them? I want the right to determine the manner and timing of my own death, but don’t want to force manner / timing on others. Nor do I want the manner and timing of my dying to be determined / forced by law or social norm.
If someone’s faith or personal beliefs prohibit medically assisted death, then that should be respected. Money, scarcity of resources, financial or other “burden” on family or society, should not be the deciding factors in a person’s manner or timing of death.
I agree with the right of the individual to die as and when he / she determines. I just don’t want this “right” to grow into an obligation to “choose death.”
AgreeThis is a complex issue with many facets. It is incumbent on the medical community to become very actively actively involved with giving Canadians all the facts.
Science has given us a new problem and we need to understand the costs to society in ways people can understand. We need to accept the fact there are limited health care resources. When we extend the life of a person beyond the point where they have any meaningful existence there are other medical priorities that have no funds. A family cannot be allowed to have access to almost infinite medical resources because of non science based views.
In addition there needs to be a template acceptable to both the Medical community and the legal community that allows a living person to make a binding statement on how his or her end of life is to be managed. We need to remove the threat of legal action that at present seems to cloud many end of life decisions.
AgreeInterventions that are “medically” futile might not always be worthless to a patient or family, and this distinction should be part of a “societal conversation”. For example: not withdrawing treatment on grandpa who is dying from his stroke, until an out-of-town family member can arrive in another 24 hours to say goodbye, or offering palliative chemo to a young mom who wants 3 more months with her children. Although these might be futile in a medical sense, proceeding with the treatments could provide time with the patient that the patient & family deem valuable enough to justify the intervention. Do we, as a society, want to allocate some of our resources to this kind of intervention? Framing the question in this way might help alleviate the adversarial situation of a doctor who thinks treatment is a waste of time & resources (because it is medically) and a pt/family who thinks it is not (because it provides something the pt and family value).
Euthanasia & physician assisted suicide (PAS) have been mentioned in this discussion. The phrase “dying with dignity” is often used to advocate them. If all physicians (and health care professionals) treated patients and their families with real dignity (that is to say, if we saw each person as having inherent worth and acted accordingly) it would be next-to-impossible to euthanize a fellow human being.
In 1999 a researcher at a Grand Rounds I attended reported on an anonymous survey from the Netherlands. Doctors admitted to euthanizing patients to free up hospital beds. Anyone who thinks this sort of abuse of the system would not happen in Canada is being naive.
(All doctors know there are all kinds of “abuses”- some more significant than others – within the health care system – as in every workplace setting.) And anyone who cares about dignity for others – not to mention themselves when they are eventually dying – ought to take care when advocating euthanasia/PAS.
AgreeHonesty by the doctors, who so often seem to find the subject uncomfortable to discuss with families, would be a good beginning.
AgreeAlso consistency. When doctors change rotations on a weekly or biweekly basis each comes with a different approach. We need honesty and consistency.
I deserve my human rights.
AgreeI have outlived my sixteen-year old daughter and had to make choices I hated at the end of her life but it came down to this: prolonging life is good, prolonging death is a horrendous -even immoral- ill. If we had not been surrounded by caring and experienced end-of-life specialists who not only made this distinction clear to us but also understood it our daughters’ death would have been made even more unbearable. Physicians: do not prolonge death in the name of medicine.
AgreeA living will will solve many problems, one that may be written and copy given to hospital, doctor and lawyer. There should not be any difficulties with family because the patient has stated his wishes, if there are problems, the family does not count, the patient’s living will, or verbal orders are to be respected and followed. As one who is living to a time line, due to heart, stroke and final stages of COPD, if I could pass peacefully, before I lose to much more weight, I would seek a cocktail or needle and just fall asleep at a time of my choosing. My body, my life my choice .. your body, your life, your choice. This is not immoral, my god is a kind god and he has given mankind medicine and science to alleviate pain and suffering. My choice, and to treat a dog better when it is time to put it down shows the immorality of our system and an absence of real compassion for the ill.
AgreeIf death with dignity were a legal option it would free up hospital beds and provide relief for the patient and their family. The long process of dying is far too stressful for many patients and their families and also an unnecessary waste of our medical resources. This drives up our medical costs and wait times for other patients. My sister chose to die at home with drugs to ease her pain but without surgery or chemotherapy after being diagnosed with pancreatic cancer. Her doctors supported this decision and provided support and information to the family regarding her care and what to expect as her 2 year journey continued. Luckily she had many friends and family members willing and able to ease her final months but many others do not have that option.
AgreeAs a nurse with 45 years of experience I believe that it is time for everyone to have a talk with their doctor about end of life decisions. Certainly every physician should have a frank talk to patients over 60 about their future. The one day I thought I would quit being a nurse was when a 99 year old lady with gangrene fully up both legs and in multiple organ failure being put through tests and treatments while tied down begging to die. It was so futile and seemed like total abuse. I was reprimanded by the doctor for speaking to her family about it. Fortunately all the rest of the staff including some of the doctors agreed and the next day she died peacefully with all treatments removed and morphine to ease her pain. Cancer is another area where patients are not given the straight facts about their chances of survival when they undergo painful treatments and spend their last months in agony instead of taking the days they have left and living them fully. Families need to be educated as well as often it is their guilt about neglecting a parent that motivates them to push for all measures. It is in fact cruel to prolong dying instead of putting our health care resources to PROLONGING LIFE. Death is the final stage of life. Why are we afraid to embrace it when it comes.
AgreeWe have had several family members who’s illnesses were treated beyond what I would personally want done for me. The extended length of some of their live were mainly made up of more doctor visits, treatments, disabilities, drugs all to no avail. There were some short times when some quality of life could be enjoyed although rare and short. Great stress is suffered by all in these situations. The docs were honest and I personally appreciated that.
Agree#1 Yes, a societal conversation is critical right now, before these issues become overwhelming.
Agree#2 Thankfully my remaining grandmother and parents have made their wishes clear in advance of having to make these decisions. Unfortunately there is no legal/medical framework to ensure that their wishes are respected at this time.
#3 I haven’t been in this situation, and I hope that I never will be if these issues can be addressed collaboratively, respecting the patients wishes, the relatives’ input, and the professional values that we depend on.
The organization Dying With Dignity would be a great resource for anyone trying to approach and deal with any of these issues.
More education on Medical futility could reduce peoples reluctance to make a firm decision.when its about money and lack of resources Dying with Dignety will be the in thing.
Agreei think we all should be allowed too make our own decision when it comes our time
AgreeAs a member of Dying With Dignity, I would like to know what proportion of family doctors in Ontario believes in a dignified death and would be prepared to help a patient to achieve this.
AgreeThank you.
I work on Pal unit for many years. I think patient loose control over their body the moment they hear news cancer. They are forced into treatment too early. Why oncologists force to take toxic chemo without knowing themselves the cause of cancer, without giving patient time to digest the shocking news, without believing that they can cure- is beyond my comprehension. Poisonous chemo just shrink the tumor and suppress the symptoms not heal. Patient should have control and choice throughout his journey and doctor should be his guide not pusher of toxic drug
AgreeI think we people should educate yourselves when we are still healthy, to be prepared when faced with terminal illness. It will be too late to learn when sick. Cures of chronic diseases in Canada is worse year by year as the cause is never found. Children and young adults are dying of cancer. Very sad. We need strong medicine which is based on true science not on fabricated evidence and probability.
AgreeUnder no circumstances would I ever agree that doctors should have the sole power over life and death. As a person living with a disability whose own doctor talks about me but never to me, whose doctor knowingly made my abusive parent my SDM and after reading through these comments in which lives like mine are described as a burden, a drain, undignified and a waste all I can say is that doctors cannot be trusted with such powers. Many patients and families do not trust Canadian doctors and all one has to do is read through these comments to see why. If you want to help people make tough choices then start treating them as people and not a burden, waste etc.
AgreeAfter 15 years of practice in oncology and palliative care I can only recall a few cases in which we had extreme difficulty in obtaining comfort for the patients. Terminal sedation has become embraced as a natural option for those individuals with intractable & severe symptoms and virtually no QoL. In those situations, there were no disagreements among family members. In the undergraduate medical education program at our University, we introduce the concept of a Goals of Care meeting for palliative and EOL care in the 6th week of medical school. Having these discussions early on in medical education primes students to consider this ‘standard practise’. The goal of course is to allow one to clearly document of their wishes under various possible scenarios. I fully respect that illnesses other than cancer, such as ALS, severe brain injury/death, advanced MS; provide more complicated EOL scenarios….but having this conversation early can only help ensure the patient’s wishes are expressed, documented, and eventually shared with the family members who are power of attorney (if that is desired). Increased funding for ambulatory palliative care services is needed so opportunities for discussing these important issues are frequent. There is enough evidence to support the use of ambulatory clinics to minimize hospitalizations and improve quality of life. Many communities have no such clinics.
AgreeI believe that the concept of Advance Directives should be introduced to the patients by their Family Physicians. The Family Physicians should discuss this with their patients at least every 3 years. This encourages our patients to start thinking about the Advance Directives and do research on it. Through this, the Family Physicians would be able to discuss end of life care with their patients and be able to answer their questions.
AgreeWe have some objective data on the expected benefit of offering prolonged, technologically intense care based on age, comorbidities, and severity of illness. Technologically intense, invasive, and expensive healthcare where the outcome is very likely to be death regardless of what is offered should not be the standard of care. Our public healthcare system should fund evidence-based therapies where there is a reasonable hope of a good outcome As such, if patients/families want anything other than this, perhaps rather than not offering it at all, there needs to be a way they can pay supplemental premiums to OHIP or even pay out of pocket for this. As unpalatable as this may sound, sustainability of our system without jeopardizing all the other important initiatives public funds are for is paramount. This is not without precedent (NICE in UK, etc), but would require a major shift in public preception/opinion and some serious political will to accomplish.
Agreewhen at least 2 independent medical experts have agreed that the treatment is futile, at that point the treatment should be considered an uninsured service and the family must become responsible for the costs, if they want to go against their advice.
AgreeIt’s that simple.
Suicide has been considered a crime, and rightly so. Assisting with suicide is totally outside a physician’s defined role. We have reached the point where older people are dreading going into hospital for fear of being exterminated. If family members want to kill a relative they should not/not involve a trusted physician.
AgreeWith regard to providing ineffective therapy it is within the purview of the responsible physician to decide. Responsible end-of-life care involves providing water and food and just sufficient medication to avoid excess discomfort on the part of the patient.
A person’s life is something to cherish, nurture, love and celebrate from conception to natural death. Life and the healing thereof extend not only to the physical but the emotional and spiritual. No aspect of a physicians care should put an end to life or hope. Neither should a physician be bound to do so against their will or beliefs.
AgreeFROM A RETIRED NURSE:
AgreeDIGNITY IN END OF LIFE CARE:
WHAT THEY CALL PALLIATIVE CARE IS NOT !!!
Covering Mom with Family Members visiting overlapping vigilance was crucial to managing her Pain in advocacy ..BUT ONLY EVENTUALLY.
For 3 days I was requesting better pain management:seeing & hearing Mom moaning in pain after ten minutes after a Sub Cutaneous injection WAS NOT giving her relief!!!
WHAT THEY CALL PALLIATIVE CARE..IS NOT !!!
Evidence of lack of real STAFF TRAINING for END OF LIFE CARE.
My Brother even asked the Supervisor Nurse what’s the transport System in her dehydration condition to deliver these injections?
When the Supervisor verified her chart …she said it was because it was ordered PRN (every 4 hours as needed)by the Doctor ….meaning depends on the Health Worker(not a Nurse)During Nightshifts workloads can be 40 patients .So she procured a new order NOT PRN. Mom was assessed every hour for pain status.And Family could phone at nightshift when- ever to check on her status.
Our family did not know doctors unilaterally put DNAR on our Matriarchs chart. She had become diabetic and when she became unwell sent her for cat scans of the head, neglecting the obligatory blood glucose! It is unbelievable to think ICU Doctors did not know what to do. Did they use their DNAR to get rid of her? Is there any other reason they neglected to do what anyone knows they must do when a patient is Diabetic? No Doctor should be allowed to DNR / DNAR a patient without asking a families permission, or even telling the family what they had done secretly.
Agree