Facing the End of Life Cannot Be Easy

An Owl in the Dubai Desert. (Dr. Noorali Bharwani)
An Owl in the Dubai Desert. (Dr. Noorali Bharwani)

Right now, I know three individuals who are terminally ill. Two are my close friends and one is a close relative. I have known them for many years. It is hard to write how I feel about this.

Sometimes, I wonder, why some people die suddenly (like my dad, brother and sister died) or die from a terminal illness that can go on for weeks and months (like my mom, and other sister died).

I am pretty sure everybody has thought about how they would like to die. There are pros and cons to sudden death versus prolonged death. Now Canadians with incurable illness have a third option called medical assistance in dying (MAID).

Dying is part of life. Dying with dignity is everybody’s desire. Some are afraid to die because we don’t know what it feels like or what will happen once our heart stops beating and we stop breathing.

Is it possible to die with dignity? There are many end-of-life care options. For example: palliative care in an institution, do not resuscitate orders, refusal or withdrawal of treatment, palliative sedation to ensure comfort and finally MAID.

Before we discuss medical assistance in dying (MAID), I would like to mention one name – Dr. Jack Kevorkian (1928 – 2011). He was an American pathologist and euthanasia proponent, who gained international attention through his assistance in the death of more than 100 patients, who were terminally ill.

He publicly championed a terminal patient’s right to die with physician’s assistance, embodied in his quote, “Dying is not a crime”. He was convicted of murder in 1999 and was often portrayed in the media with the name of “Dr. Death”. There was support for his cause, and he helped set the platform for reform. He spent eight years in jail for assisting a patient with Lou Gehrig’s disease to die.

It has taken almost 30 years for Dr. Kevorkian’s dream come true.

According to Health Canada website, on March 17, 2021, the Government of Canada announced changes to Canada’s MAID law. The new law includes changes to eligibility, procedural safeguards, and the framework for the federal government’s data collection and reporting regime.

The law clearly defines who may be eligible to obtain MAID and the process of assessment. The law ensures eligible Canadians will be able to request MAID according to the new law, and that the appropriate protections are in place.

Physicians and nurse practitioners can legally provide MAID.

Pharmacists, health care providers and family members can legally help. These people can assist in the process without being charged under criminal law. The federal legislation does not force any person to provide or help to provide MAID if it is against their religious or other beliefs.

There are two types of MAID available to Canadians. They each include a physician or nurse practitioner who directly administers a substance that causes death. Second option is known as self-administered MAID. A doctor can provide or prescribe a drug that the eligible person takes, in order to bring about their own death.

Several conditions have to be met to be eligible for MAID. A person should be at least 18-years-old and mentally competent. Should have a grievous and irremediable medical condition, make a voluntary request for MAID that is not the result of outside pressure or influence, and give informed consent to receive MAID.

We know one day we are going to die. To die with dignity is the best way to go. How do we prepare for that? There are no simple answers. As Woody Allen said, “I am not afraid of death. I just don’t want to be there when it happens.”

I wish you all good health, happy times with long life.

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What you should know about medical assistance in dying – MAID?

Toronto Waterfront (Alia Bharwani)
Toronto Waterfront (Alia Bharwani)

“I’m not afraid of being dead. I’m just afraid of what you might have to go through to get there,” said Pamela Bone. Bone, 68, was a columnist and associate editor of the Age, one of Australia’s most respected newspapers. She died of terminal cancer. She was also a passionate campaigner on the right to die.

In Canada, following a Supreme Court ruling, medical assistance in dying became legal on June 6, 2016.

Recently (June 2018), the Canadian Medical Protective Association (CMPA) wrote, “Despite current federal and Québec legislation that makes medical assistance in dying (MAID) legal, there continues to be uncertainty among some physicians about their rights and obligations, and the processes to be followed in this area.”

A June 2016 Canadian Medical Association (CMA) survey revealed 25 per cent of responders (doctors) would be willing to provide MAID and 61 percent would not. Under the new law, Canadian doctors are not compelled to provide MAID. In these cases, the doctor is required to provide a referral to a health care professional or agency willing to carry out the patient’s wishes.

What kind of challenges physicians may face in determining eligibility for MAID? CMPA says there are several areas of concern. First, how can a doctor define and predict “reasonably foreseeable death” before enlisting an individual for MAID? Can a doctor be a conscientious objector if MAID does not agree with his/her beliefs? And there are other issues not well defined in the law.

Court challenges are underway in British Columbia and Québec in which the issue is whether the requirement that “natural death be reasonably foreseeable” is too restrictive and violates patients’ constitutional rights.

Physicians should remember that unlike most other healthcare services, MAID is governed by criminal law. Failure to ensure that the safeguards and eligibility criteria, as well as the reporting requirements for MAID are met could result in criminal charges and imprisonment of up to 14 years, in addition to College sanctions, civil legal actions, or both, says CMPA.

There are several other issues to be considered when implementing MAID:

  • Is there a risk that the law will be abused to weed out society’s undesirable people? In Canada, patients need to meet specific eligibility criteria put in place to safeguard vulnerable people. The patient must be mentally competent and give informed consent.
  • Is MAID a legal way to commit suicide? Committing suicide and going through physician-assisted dying are legally two different things. A medically assisted death is well planned and thought out, while suicide is often impulsive, violent and carried out alone.
  • Prior to Canada’s new law, it was illegal for anyone to counsel or coerce someone to die by suicide. The current Criminal Code now includes an exemption for physicians, nurse practitioners, and pharmacists – they are now allowed to counsel patients.

Alberta Health says its goal is to provide access to physician-assisted death, while protecting vulnerable Albertans and respecting the rights of physicians and other health professionals. To achieve this goal, the law should provide better clarity to protect the health care providers if they have to help those who are eligible for MAID.

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Euthanasia vs. The Power of Prayer

Terminal care is physically demanding and emotionally nerve wracking. Most families have had the experience of dealing with a family member or a relative who was dying of an incurable illness. They see the ill person suffer from pain, pneumonia, urinary tract infection, back pain, bed sores, sleepless nights, shortness of breath, bowel obstruction, stomach tube, constipation, enemas, multiple pills, multiple injections, confusion, delirium, fear, anxiety, depression …the list goes on and on.

My mother’s last few weeks in this world were no different.

She knew she was going to die. In her room, in a Calgary hospice, she wanted the clock on the wall where she could see the time clearly. During the day, she would ask, “How come the time is moving so slowly?” In the silence of the night, I wondered if she could hear the clock tick telling her that although her time was up, she will have to wait for her turn to die.

The place of her death was already decided, it was not going to be her home in Calgary. Her wish to die at home could not be fulfilled because, after four months of gradual deterioration in her health, the nursing care provided by the members of her large family came to an end when they were physically and emotionally exhausted. The family was rescued by the wonderful people at Home Care, Palliative Care, Foothills Hospital and Agape Hospice.

Now, who was going to decide on the timing of her death?

My mother was a deeply religious woman. She believed in the power of prayer and prayed very hard to God to end her life and stop the misery of pain and indignity. She requested all her visitors and family members to pray for her quick end. During her better days she used to ask me to promise her that I, as her physician-son, would not let her suffer if she was terminally ill and in pain. She wanted me to end her life with some medications. I explained to her that such actions were not legal in this country.

When she was diagnosed with terminal gynecologic cancer, she reminded me of our discussion about euthanasia. When she was in the hospice suffering, I felt she was a right candidate for euthanasia. In the last few days of her life she could not find a comfortable position in bed. She could not get out of bed and she had lost control of her bodily functions. She could not breathe comfortably.

The slowly growing pelvic tumor had made her abdomen very large and eaten away all her body fat and had wasted all her muscles. She had quit eating due to constant nausea and abdominal fullness. She was weak and frail. Every movement was painful.

Lately, she was sleeping a lot with the help of morphine. Each day there were few hours of bright moments. She would watch her favourite television shows. She would listen to her favourite religious songs. She enjoyed all the visits and phone calls she received from friends and relatives locally and from all over the world. Her memory never lost her but her hearing gradually got worse and her voice gradually got weaker. The end was near.

Finally, her prayers were answered. Her role as a wife, mother, grandmother, great grandmother and great great grandmother came to an end at 7.40 p.m. on Saturday April 19, 2008 in the presence of family members. It was end of an era. She was the matriarch of the family. At 87, she was the last surviving member of her and my dad’s siblings.

The power of prayer had won.

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Euthanasia – is it murder or mercy?

Recent editorials in this newspaper have examined the Dutch government’s proposed legislation to legalize euthanasia under tight guidelines.

Euthanasia is a Greek word meaning “good death”. Webster’s encyclopedic dictionary of the English language describes euthanasia as the deliberate, painless killing of persons who suffer from a painful and incurable disease or condition, or who are aged and helpless.

Canadian Medical Association’s Code of Ethics for physicians says that passive euthanasia (allowing patient to die by witholding treatment) is morally permissible in certain circumstances. But active euthanasia (taking measures that directly cause a patient’s death) is wrong.

The issue of euthanasia is not new. Part of the Oath of Hippocrates says: I will follow that method of treatment which, according to my ability and judgement, I consider for the benefit of my patients, abstain from whatever is deleterious and mischievous. I will give no deadly medicine to anyone if asked nor suggest any such counsel.

Gradually, people’s opinions have changed. In the last 10 years, North American surveys have shown that public consistently show strong acceptance of mercy killing and regulated physician-assisted suicide, says Dr. Douglas Kinsella, MD, in a study published in the June 1999 issue of the Annals of the Royal College of Physicians and Surgeons of Canada.

Significant proportions (49 percent) of Canadian Physicians accept its morality and future legalization, and would wish it for themselves and close relatives, if legalized.

Two recent Canadian court cases of euthanasia are well known to the public. Cases against Dr. Nancy Morrison and Mr. Latimar.

In US, Dr. Jack Kevorkian, otherwise known as Dr. Death, took this issue to a new level when physician assisted death of Mr. Thomas Yourk was shown on television. Dr. Kevorkian is seen to inject the lethal drug. On previous occasions, Dr. Kevorkian has let the patients inject themselves so the doctor does not get legally implicated in the process.

It has been 10 years since Dr. Kevorkian, a retired pathologist, started his “mission” to help terminally ill patients die with dignity. He has assisted in more than 100 deaths. He has been charged and acquitted by juries atleast three times. In Mr. Yourk’s case, he was convicted. Mr. Yourk lived in Michigan, which bans assisted suicide.

Oregon has legalized euthanasia (The Oregon Death with Dignity Act). But the controversy continues. There is continuous process to monitor the use and abuse of the Act.

Netherlands established guidelines on euthanasia in 1984. One of the requirements is that the patient should make a voluntary request to die. A study shows that in 1990, there were 900 cases of non-voluntary euthanasia recorded. Now the Dutch government is going to legalize euthanasia. Is that going to change anything?

Whether anything is legal or not, certain individuals in society will continue to abuse the system either for selfish reasons or because they feel they are morally justified. How can you change that?

Besides, who decides if euthanasia is morally and legally right? Why do we accept that it is all right to watch people suffer and die slowly but it is wrong to practice active euthanasia?

Reasonable thing should be to offer euthanasia to the right people, at the right time, for the right reason, at the right place, by the right individuals and in the most dignified and humane way! Is that possible?

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