End of Life

Curricular Objectives

1. To become familiar with the definitions, distinctions, and legal status of euthanasia, assisted suicide, palliative care, and decisions to forego life-sustaining treatment
2. To develop a framework for managing end of life issues in surgical patients

Summary of Case

Mr. M is a 65 year old supply depot manager with esophageal cancer. He has undergone five operations to treat complications of his disease and its treatment. The tumour persists, and infection is present. Mr. M went into respiratory failure. The family agreed to discontinue the ventilator. The patient continues to breathe spontaneously off the ventilator, but later begins to gasp for air. What do you do?

Lesson Plan

The first 10 minutes is spent discussing the management of Mr. M: What would you do, when the nurses say, "Do something, Doctor!"; What treatment, drug, dose, route, etc? Do you write an order and then leave the unit? Writing the suggestions on the board helps to keep them before the group throughout the subsequent discussion. Social, spiritual, and psychological support should be elicited in addition to pharmacologic and physical interventions. The rest of the lesson can be conducted as a facilitated discussion based on this series of questions:

Answer:
A deliberate act undertaken to end the life of another person to end suffering; the act is the cause of death.

Answer:
The act of intentionally killing oneself with the assistance of another who deliberately provides the knowledge, means, or both.

Answer:
The main arguments supporting legalization of euthanasia/assisted suicide are:

• Respect for patient autonomy. Patients have a right to determine the time and manner of death.
• Permanent relief of suffering.
• Doctor-patient relationship implies a duty of beneficence: the doctor should act with mercy and kindness.
• Current laws discriminate against physically disabled persons who cannot commit suicide.

Answer:
The main arguments against legalization of euthanasia/assisted suicide are:

• Respect for human life.
• Fear of abuse - the "slippery slope" argument.
• Protection of vulnerable people such as elderly or demented patients.
• Doctor-patient relationship implies a duty of the doctor to do no harm.
• Medical profession may lose integrity and public trust if killing becomes a medical procedure.
• Legal change is not necessary because palliative care provides relief of suffering and is what most people want.

Answer:
The term "euthanasia" does not appear in the Criminal Code of Canada. Any act of euthanasia would be a form of homicide. The penalty for first degree murder, the most serious form of homicide, is life imprisonment with no eligibility for parole for 25 years. Neither committing suicide nor attempting to do so is a crime. However, assisting or counselling suicide is a crime, for which the penalty is up to 14 years imprisonment. A committee of the Canadian Senate recently recommended that assisted suicide should remain a criminal offense. The committee also suggested that the penalty for homicides motivated by compassion should be reduced. Parliament has not acted on this suggestion.

Answer:
In the United States, legislators of individual states have the legal authority to establish criminal law regarding assisted suicide and euthanasia. The US Supreme Court recently upheld state laws against assisted suicide, but refused to strike down Oregon's law which legalizes physician-assisted suicide. In summary, the Court is leaving the issue to be worked out at the level of the states. Euthanasia is technically illegal in the Netherlands, but it is tolerated by prosecutorial discretion, when practised under strictly defined conditions.

Answer:
Euthanasia and assisted suicide involve the injection of a lethal substance or the provision of a lethal overdose whereas decisions to forego treatment involve the non-initiation or discontinuation of a life-sustaining treatment such as CPR, ventilator, tube feeding, etc. The law permits discontinuation, even though it leads to death, under defined conditions. If the patient and the family do not agree to discontinuation, or if the decision is made on insufficient evidence of irremediable illness, caregivers may be held liable. When death results from treatment to relieve suffering, legal charges are highly unlikely if the physician's actions meet all of the following three criteria, which represent appropriate palliative care in the eyes of the law:

1. There is subjective or objective evidence that the patient is experiencing pain or distress.
2. The physician's therapeutic response is commensurate with the level of the patient's pain or distress and there is evidence of an ongoing feedback loop between the patient's symptoms and signs and the physician's therapeutic response.
3. The physician's actions do not represent the direct infliction of death.

Answer:

• Respect a decision to forego or discontinue treatment expressed by competent patients or conveyed by reliable surrogates.
• Proceed slowly and consult widely whenever irreversible decisions are made, especially when your decision conflicts with cultural norms.
• Learn effective techniques of palliative care and work to insure its availability.
• Provide palliative care, including a proportionate response using appropriate pain medication - do not use KCl.
• Do not accede to requests for euthanasia or physician assisted suicide.
• Explore reasons and alternatives when patients request euthanasia or physician assisted suicide.
• Do not participate in euthanasia and physician assisted suicide, which are violations of the criminal code, under the mistaken notion that you are using civil disobedience as a protest to laws you might disagree with. If you disagree with the law, use the political process to bring about change.
  

Bioethics Bottom Line

Although decisions to forego life-sustaining treatment are legally permissible in Canada, euthanasia and assisted suicide are illegal. Euthanasia can be defined as an action that is intended to lead directly to the death of a patient; the prototypical example is an injection of potassium chloride. Assisted suicide can be defined as the provision of the means, knowledge, or both for euthanasia to a patient, who then uses those means and/or knowledge to commit suicide.

In the United States, legislators of individual states have the legal authority to establish criminal law regarding assisted suicide and euthanasia. The US Supreme Court recently upheld state laws against assisted suicide, but refused to strike down Oregon's law which legalizes physician-assisted suicide. In summary, the Court is leaving the issue to be worked out at the level of the states. Euthanasia is technically illegal in the Netherlands, but it is tolerated by prosecutorial discretion, when practised under strictly defined conditions.

These legislative initiatives, as well as the Rodriquez, Latimer, and Morrison cases, have focused attention on the ethical arguments supporting and opposing euthanasia and assisted suicide. The main arguments supporting the legalization of euthanasia are respect for patient autonomy, the relief of suffering, the doctor-patient relationship in which the doctor is to treat with beneficence, and non- discrimination against physically disabled persons who cannot commit suicide. The main arguments opposing its legalization include respect for human life, fear of abuse, protection of vulnerable people, the doctor-patient relationship in which the doctor is to do no harm, concern that the medical profession would lose the trust of the public if killing were to become a medical procedure, and the availability of palliative care to provide relief of suffering.

It is easy to distinguish euthanasia and assisted suicide from decisions to forego treatment; euthanasia and assisted suicide involve the injection of a lethal substance or the provision of a lethal overdose, whereas decisions to forego treatment involve the non-initiation or discontinuation of a life-sustaining treatment such as CPR, ventilator, tube feeding, etc. The law permits discontinuation, even though it leads to death, under defined conditions. If the patient and the family do not agree to discontinuation, or if the decision is made on insufficient evidence of irremediable illness, caregivers may be held liable. 

When death results from treatment to relieve suffering, legal charges are highly unlikely if the physician's actions meet all of the following three criteria, which represent appropriate palliative care in the eyes of the law:

1. There is subjective or objective evidence that the patient is experiencing pain or distress.
2. The physician's therapeutic response is commensurate with the level of the patient's pain or distress, and there is evidence of an ongoing feedback loop between the patient's symptoms and signs and the physician's therapeutic response.
3. The physician's actions do not represent the direct infliction of death.
   

References

Lavery J, Boyle J, Dickens BM, Singer PA. Bioethics for clinicians: 11. Euthanasia/Assisted suicide. CMAJ 1997; 156: 1405-8.

Loewy EH. Problems in the care of the terminally ill. In Loewy EH, Textbook of healthcare ethics. New York: Plenum Press; 1996. p. 191-2.

Further Reading

Annas GA. The bell tolls for a constitutional right to physician-assisted suicide. N Engl J Med 1997; 337:1098.

Doyle D, Hanks GWC, MacDonald N. Oxford textbook of palliative medicine. New York: Oxford University Press; 1993.

Lowy FH, Williams JR, Sawyer D. Canadian Physicians and Euthanasia. Ottawa, CMA, 1993.

Miller FG, Quill TE, Brody H, et al. Regulating physician-assisted death. N Engl J Med 1994; 331: 119-23.

Quill TE, Cassel CK, Meier DE. Care of the hopelessly ill: Proposed clinical criteria for physician- assisted suicide. N Engl J Med 1992; 327: 1380-4.

Walsh D. Palliative care: Management of the patient with advanced cancer. Semin Oncol 1994; 21 (4 Suppl 7): 100-6.

Disclosure

Bioethics

Medical Ethics and CanMeds Principles