Hastened death due to disease burden and distress that has not received timely, quality palliative care is a medical error

Canada's Medical Assistance in Dying System can Enable Healthcare Serial Killing

The Canadian approach to assisted dying, Medical Assistance in Dying (MAiD), as of early 2024, is assessed for its ability to protect patients from criminal healthcare serial killing (HSK) to evaluate the strength of its safeguards. MAiD occurs through euthanasia or self-administered assisted suicide (EAS) and is legal or considered in many countries and jurisdictions. Clinicians involved in HSK typically target patients with the same clinical features as MAiD-eligible patients. They may draw on similar rationales, e.g., to end perceived patient suffering and provide pleasure for the clinician. HSK can remain undetected or unconfirmed for considerable periods owing to a lack of staff background checks, poor surveillance and oversight, and a failure by authorities to act on concerns from colleagues, patients, or witnesses. The Canadian MAiD system, effectively euthanasia-based, has similar features with added opportunities for killing afforded by clinicians' exemption from criminal culpability for homicide and assisted suicide offences amid broad patient eligibility criteria. An assessment of the Canadian model offers insights for enhancing safeguards and detecting abuses in there and other jurisdictions with or considering legal EAS. Short of an unlikely recriminalization of EAS, better clinical safeguarding measures, standards, vetting and training of those involved in MAiD, and a radical restructuring of its oversight and delivery can help mitigate the possibility of abuses in a system mandated to accommodate homicidal clinicians.

Canadian Medical Assistance in Dying: Provider Concentration, Policy Capture, and Need for Reform

Canada's rapid rise in deaths from euthanasia and physician assisted suicide, termed Medical Assistance in Dying (MAID) in the country, now ranks it second only to the Netherlands in terms of MAiD deaths as percentage of overall deaths, with one province already hosting the highest rate of all jurisdictions in the world. Analyzing Health Canada's annual MAID reports, which show that up to 336 out of 1837 providers are likely responsible for the majority of MAID deaths in a given year, we discuss how the rapid increase likely reflects not a broad Canadian consensus but the capture of a policy-making and implementation process by a small group of activists and clinicians colonizing medicine to become an ideologically driven vehicle for expanding MAID access and delivery. As a remedy and to reprioritize patient safety and protection against premature death, a more transparent, relevant, and safeguarded compliance regime based on evidence-based, multi-perspective policy-making is needed.

Human misconnection? A response to Beuthin and Bruce on medical assistance in dying providers' lived experience

Beuthin and Bruce's study 'MAiD as human connection: Stories and metaphors of physician providers existential lived experience' in this journal describes the affective experiences of Canadian Medical Assistance in Dying (MAiD) providers. A critical response to this work shows it is based on flawed premises and interpretations of its data, which centers on praising its participants in lethal injection for their very positive emotions. Their study also seems to unproblematically construct people dying by MAiD as "the other," a term that usually describes members of groups subject to individual and systemic oppression. Contextualized, their paper can be read to show how some MAiD providers may affectively and financially benefit from providing death to, and at the expense of, their suffering patients and grieving and possibly traumatized family members and witnesses. Beuthin and Bruce's study sheds new light on the provider side of MAiD and assists the case for vetting and setting suitability criteria for MAID clinicians.

Tipping Point: Pathogenic Stress and the Biopolitics of Euthanasia

Hopelessness and demoralization following a terminal diagnosis can affect the capacity for self-governance. Such dispositions can increase the allostatic load-the cumulative burden of stress and anxiety-resulting in a neurophysiologic decline that can impair autonomy and influence the desire to end one's life deliberately. An allostatic overload is characterized by the inability to autoregulate stress and is associated with pathological changes to the hypothalamic-pituitary-adrenal axis and hippocampus. These changes raise concerns about the reliability of concepts of autonomy in extremis, potentially undermining arguments that are used to justify voluntary euthanasia and medically assisted death. Studies have associated depression and hopelessness with suicidal ideation in the general population. However, fewer studies have examined how patients without a history of depression or suicidal ideation may suddenly contemplate the act when facing a terminal prognosis. This paper will argue that an allostatic overload can help explain how the spectrum of physical and psychological comorbidities associated with the onset of a terminal illness can influence a decision to hasten death. Data show that patients with a terminal disease wishing to hasten death typically exhibit lower rates of clinical depression, higher rates of demoralization, and a greater likelihood of rational suicide. These differences indicate that suicidal ideation in the terminal disease patient population is different. Changes in autonomous decision-making secondary to pathological alterations in the brain may offer an explanation. Such changes have been shown to dysregulate executive control functions, specifically intentionality and voluntariness. Clinical evidence also indicates that spirituality and hopefulness can help manage the allostatic load during the palliative stages of a disease so that patients can better process end-of-life decisions. Based on these data, this paper will further argue that jurisdictions offering euthanasia are morally compelled to make mental and spiritual counseling available to patients seeking this course of action.

'I secretly wish. . .' Caregivers' expression of wish for death of persons with severe dementia

BACKGROUND

Qualitative evidence suggests that caregivers may express a wish for death of persons with severe dementia (PwSD). No study has assessed the extent to which it happens, stability of this wish over time and the factors associated with it.

OBJECTIVES

We examined caregivers' wish for death of PwSDs overtime and the factors associated with this wish.

METHODS

215 caregivers of community dwelling PwSDs were surveyed every 4 months for 2 years. Using the mixed-effects multinomial regression model, we assessed the PwSD and caregiver factors associated with caregivers' wish for PwSDs' death.

RESULTS

At baseline, 27% caregivers expressed a wish for PwSDs' life to end sooner. Overall, 43% of the caregivers expressed a wish for PwSDs' death at least once during the study period and 11% expressed it consistently. Caregivers' perception of PwSDs' lower quality of life (RRR: 1.05, 95% CI: 1.00, 1.10), higher functional dependency (RRR: 1.1, 95% CI: 1.01, 1.21), eating difficulty (RRR: 2.25, 95% CI: 1.26, 4.04) and suffering (RRR: 1.92, 95% CI: 1.05, 3.52) were associated with this wish. Caregivers who were emotionally close to PwSDs were less likely (RRR: 0.25, 95% CI: 0.11, 0.55) while those who understood that dementia is a terminal illness were more likely (RRR: 2.01, 95% CI: 1.03, 3.92) to express this wish.

CONCLUSION

Caregivers' wish for PwSDs' death changed over time and was primarily driven by their perception of PwSDs' poor well-being and awareness of their illness being terminal, indicating a need for increased support in this challenging caregiving context.

A Sceptics Report: Canada's Five Years Experience with Medical Termination (MAiD)

This article seeks to assess the results of legislation legalizing medical termination, known in Canada as "medical aide in dying" in 2016. Its focus, like that of previous authors, is to ask if the concerns of skeptics opposed to legalization have been realized or were they unfounded. These include the likelihood of a "slippery slope" with an expanding definition of eligibility and of MAiD deaths. Of similar concern at least since 1995 was the likelihood that, in the absence of the provision of palliative, rehabilitative, psychological and social services that medical termination would be a substitute for good medical care. These and other concerns are the basis for the review of MAiD in Canada clinically, legally and as an ethical construct.

A Catholic Perspective: Triage Principles and Moral Distress in Pandemic Scarcity

Striving to be faithful to the moral core of medicine and to spiritual, moral, and social teaching of the church, Catholic physicians see their role as an extension of the healing ministry of Jesus. When faced with a situation in which a large number of gravely ill people are seeking care, but optimal treatment such as ventilation in intensive care unit cannot be offered to all because of scarcity of resources, Catholic physicians recognize the need to consider the common good and to assign a priority to patients for whom such treatments would be most probably lifesaving. Making these evaluations, physicians will use only objective medical criteria regarding the benefits and risks to patients and will be mindful that all persons deserve equal respect for their dignity. Discrimination or prejudicial treatment against patients based on factors such as age, disability, race, gender, quality of life, and possible long-term survival cannot be morally justified. Triage process should incorporate respect for autonomy of both the patient and the professional and opportunity for an appeal of a triage decision. Other principles and values that will affect how a triage protocol is developed and applied are proportionality, equity, reciprocity, solidarity, subsidiarity, and transparency. The current coronavirus pandemic can provide valuable lessons and stimulus for reforms and renewal.

SUMMARY

Catholic physicians strive to continue the healing ministry of Jesus Christ and be faithful to the moral core of medicine. In situations such as pandemic, the scarcity of personnel and technological resources create serious challenges and even moral distress. Church teachings on dignity, the common good and protection of the vulnerable help guide decisions based on public medical criteria and shared decision-making.

A Retrospective Review of Medically Assisted Deaths in Nova Scotia: What Do We Know and Where Should We Go?

Background: Since legalization of medical assistance in dying (MAiD) in Canada on June 17, 2016, there has been limited information regarding how outcomes of those requesting MAiD relates to comorbidity, social circumstances, geographic location, and access to care. This study aims to identify characteristics associated with the completion of MAiD, once requested, with specialist palliative care (SPC) as the primary exposure of interest. Methods: This retrospective cohort study consists of all patients in Nova Scotia who requested MAiD between June 17, 2016 and December 31, 2018 and were deceased at the time of analysis (n = 383). Descriptive statistics and logistic regression were performed. Results: A smaller proportion of patients who completed MAiD were seen in consultation by SPC (69.4% vs. 81.1%, p = 0.01). SPC was associated with decreased odds of completing MAiD (odds ratio [OR] 0.59, 95% confidence interval [CI] 0.36-0.96, p = 0.04), as was cohabitation (OR 0.64, 95% CI 0.41-0.99, p = 0.05) and Charlson comorbidity index >6 (OR 0.64, 95% CI 0.41-0.99, p = 0.05). Interpretation: SPC consultation was associated with significantly reduced likelihood of MAiD completion. Contributing factors may include differences in access to SPC services, those completing MAiD being more likely to decline a consultation with SPC, or the impact of SPC upon patient preferences and access to MAiD. While the interface between SPC and MAiD is in its early stages, our findings are supportive of a more integrated approach to coordination of SPC and MAiD services.