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Euthanasia: End-of-life care hinges on recognizing and treating pain

Some people consider euthanasia because they don’t want to become a burden. (Photo courtesy of stock.xchng)

Some people consider euthanasia because they don’t want to become a burden. (Photo courtesy of stock.xchng)

If Bill 52, An Act Respecting End of Life Care, becomes law, euthanasia/medical aid to dying will be legal in Quebec.

For social services minister Véronique Hivon, who introduced the bill, the act is humane, ensuring the terminally ill, as informed consenting adults, can make end-of life choices.

She has no patience with the “charged vocabulary” of McGill bioethicist Margaret Somerville, who said that once a society allows “intentional killing … you can’t control it.” Nor does she buy Somerville’s and others’ “slippery slope” argument, claiming she trusts doctors would not abuse the law. She says there are safeguards written into the bill.

“No one wants to be killed or to kill. The person wants to stop suffering,” she said on CBC’s The Current.

On this point, Rose De Angelis, palliative nursing director at the West Island Palliative Care Residence, agrees with Hivon. “The No. 1 reason people ask to die is that they are scared of suffering. Yet we can tell them palliative care has the tools to alleviate nearly all suffering.” The second reason people consider ending their lives, De Angelis says, is that they don’t want to burden their families as their capacities diminish. “We have the beds, they are free and we provide the kind of care that makes life worth living. We have very good pain management, excellent experts.”

But De Angelis vehemently rejects Hivon’s assertion that medical aid to die is an extension of health care.

“Almost all of us are against it,” she says. “It was never part of palliative care—it is not part of our role. We’re the alternative to euthanasia, which is not on a continuum of any medical care.”

Balfour Mount, the oncologist who established the first palliative-care ward at the Royal Victoria hospital in 1973 and who coined the term, rejects the idea as well. “We have gone from the goal of improving the quality of the end of life to ending life. I don’t call that medically assisted suicide, I call it euthanasia.” He and De Angelis both made the point that “palliative sedation,” a last-resort tool to keep the dying patient pain-free, is already being used, and an injection to hasten death is not necessary. Mount is battling cancer and heart disease but says he would never ask for a doctor “or anybody else to end my life intentionally. I would far prefer to be asleep consistently until I die, as I described in my paper When Palliative Care Fails to Control Suffering, 20 years ago. The goal isn’t to kill, but to improve quality. It is a palliative goal.”

The bill outlines stringent criteria s to the requesting and administering of euthenasia. But nowhere does it explicitly say that all means to alleviate pain must have been exhausted before a patient makes that decision, however “informed”.

A study published last month by Université de Montréal’s Manon Choinière demonstrated that after the most frequently performed cardiac surgery, patients were left with persistent post-operative pain for two years, suggesting that pain remains under-treated and under recognized in our hospitals.

Mary E. Lynch, past president of the Canadian Pain Society, writes in Pain Research and Management, “Pain is poorly managed in Canada.”

In her 2010 call for a national pain strategy, she cites studies that show rates of suicide increase with pain, and among those at risk to suffer from inadequate pain management are the elderly and the very young.

“Unfortunately, even in the best hospitals in Canada, patients continue to receive inadequate pain control in emergency rooms. … Ninety percent of patients could obtain effective and safe relief of their pain with currently available treatments, yet only 50 per cent gain access to such treatments.”

De Angelis says education is an issue, noting that veterinarians receive far more hours of pain management training (one survey estimates five times more) than physicians.

“End of life care does not cost a lot when used properly,” De Angelis says. “What costs is people showing up in emergency rooms when they’re dying.”

Alex Schadenberg, executive director of the Euthanasia Prevention Coalition, also rejects Hivon’s definition of medical aid in dying as being part of health care, and notes that in the Criminal Code, euthanasia and assisted suicide are illegal. “Quebec calls it health care because it has provincial jurisdiction. Even if it is voted on it will be challenged.”

He also worries it will be extended to those with dementia and others. Recently Yves Robert, the secretary of the Collège des médecins de Québec, told the National Post that in time the question will be not about who is eligible for euthanasia but who is being denied it.

Schadenberg argues that if euthanasia is defined as health care, then as such it will have to be universal and extended to children, as it has been in Belgium. In that country, 160 pediatricians signed an open letter of protest, saying modern medicine can “perfectly” control physical pain.

“Budgetary problems, waiting lists, people not receiving the care they need; introduce euthanasia and it’s a bad mix. It is cheap, simple, and in the end a way to eliminate a lot of our problems,” Schadenberg says.

“Over time it will be seen as the answer.”

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