Wednesday, July 17, 2013

‘That terrifies us’: Canadian doctors get virtually no training on handling a patient’s desire to die | National Post

Twice every week, Dr. Larry Librach visited the patient with end-stage pancreatic cancer. And twice a week, the patient, a "deeply thinking" man with the support of his family, asked for help to end his life and avoid the disease's final ravages.
As Canadian law dictates, Dr. Librach respectfully declined every time, insisting that the patient would be sufficiently sedated in his final moments to make the end bearable.
It didn't quite unfold that way, the death being much less peaceful than planned, but the case underlined a little-known dilemma for many health-care workers. As other Canadians debate assisted suicide as a largely academic issue, doctors and nurses are routinely asked by dying patients for a medical push over the edge, specialists say.
And yet, they get little preparation for arguably the most difficult conversation they will ever have with a patient. Most doctors finish their degrees and five years of specialty training with virtually no instruction on how to deal with death generally, let alone patients who ask for help with suicide, said Dr. Mike Harlos, medical director of palliative care for the Winnipeg Regional Health Authority.
"The most frightening interface with the health care system is the dying bit. That terrifies us," said Dr. Harlos. "And yet it's the least addressed."
In response, Dr. Librach has developed a unique program to teach health professionals how to deal with assisted-death requests in a country where saying 'Yes' could lead to murder charges — and a flat 'No' might cut short an important conversation.
The course – offered through the University of Toronto's Joint Centre for Bioethics — suggests that a cry for help with suicide likely points to unidentified suffering. So health-care workers are urged to put aside their personal reservations and fear of the law to get to the bottom of those problems.
"Everybody who is terminally ill thinks about, 'Is it easier just to shorten my life?' " said Dr. Librach, former head of the centre. "You can't tell them 'Go ahead and do it' … [But] we have to at least explore the reasons why. You have to respond in an effective manner."
In a cruel irony, meanwhile, Dr. Librach – a Canadian pioneer in the palliative field — is now suffering from advanced cancer himself. Although he has no objection to assisted suicide on principle, he said he has decided against it for himself. "I'm dying and I will die naturally."
The drawn-out Canadian debate on assisted-suicide and euthanasia is in major flux: the Quebec government has introduced legislation to let doctors help end terminal patients' lives, while a constitutional challenge of the criminal ban on assisted suicide heads to the Supreme Court of Canada.
For now, the practice remains illegal, though that does not stop terminal patients asking their health-care team for a fatal remedy.
In a typical plea, "the patient says 'I wish I was dead, can't you help me die?' " said Dr. Librach.
Sometimes the appeal comes from the relative of a deeply suffering patient. "They say 'If my dad were a dog, you would just put him down. Why can't you do something?' " said Dr. Harlos.
The situation can be challenging even for those trained to deal with such issues, said Dr. Robin Fainsinger, a palliative-care physician at the University of Alberta.
"It's never going to be an easy conversation," he said.
The reasons behind the requests vary, with untreated pain being just one of many possible motives, said palliative specialists.
Sometimes the sentiment stems from a loss of control — not knowing when or how the end will come – or a worry about burdening family members, said Dr. Harlos.
In one of the Winnipeg physician's terminal cases, a highly successful businessman and all-round "alpha male" felt he essentially had nothing left to live for as he lay incapacitated in a hospital bed — and wanted help to die prematurely.
"I said, 'You're used to accomplishing things and the biggest task ahead of you is to show your family how this is done,' " said Dr. Harlos. "It inspired him to the point where he completely turned around [psychologically]."
He and Dr. Fainsinger said the vast majority of patients can be mollified by the right kind of medical help and counseling. In fact, Dr. Fainsinger said the number of terminal patients asking for help in dying has declined markedly over the last several years as palliative services became more available and effective.
Yet palliative care is no panacea for the existential anguish that makes a minority of terminal patients want to die early, argues Wanda Morris, executive director of the group Dying with Dignity. Among other services, it provides patients with information on how to take their own lives.
Some of her clients are quietly referred to the organization by nurses and other health professionals, she noted.
"Some people at end of life are saying 'I'm done with dying. I'm sitting here helpless, it's only a question of days or weeks, there's nothing for me to look forward to … Let me go.' "
Dr. Harlos said some of his patients have ended up traveling to Switzerland, where organizations like Dignitas are legally permitted to aid in suicide.
Even as his program counsels doctors and nurses how to support those wanting a speedier death, Dr. Librach himself acknowledges that medical teams do not always have the right answers, or the ability every time to bring about the peaceful endings they promise.
That patient who made repeated pleas for suicide help, for instance, was supposed to be under deep sedation when the end came, but the cancer progressed much faster than expected.
"When he did die, he died in agony: We couldn't get enough medication into him," said Dr. Librach. "He did not go gently into that good night."