Unintended casualties of Medical Assistance in Dying

There shouldn’t be much more to say about this subject. The highly contentious and divisive issue of medical assistance in dying (MAID) has been widely and publicly discussed. From a legal perspective, the issue has been settled in Canada. Citizens can now opt to have their lives ended given they fulfill certain criteria. The medical profession and our hospitals have an obligation to support patients who qualify. Individual physicians who chose to actively end the lives of these patients will be legally protected in doing so. Those who conscientiously object are not required to provide MAID but are professionally and ethically required to support their patients in making the decision and seeking the service, which is now being provided, both in and out of our hospitals. There would seem to be no need for further debate or discussion.

However, little has been written about the impact on those involved in the care of patients opting for MAID.

I’ve recently been hearing from medical students who, in the course of clerkship rotations, became involved with patients who elected for medically assisted death. They have found the experience, to say the least, highly unsettling.

For those readers not familiar, senior medical students, in the course of their clinical placements, will become part of medical teams caring for groups of hospital in-patients. The medical student is the most junior member of that team, consisting of graduate physicians training in particular specialties and supervised by a fully qualified Attending Physician. The student is assigned a small number of patients who they are expected to assess and follow throughout their hospital stay. They report regularly on their patients to senior residents and the Attending Physician who review the patient with them and must approve all investigations, treatments and major decisions.

In the course of these rotations, medical students get to know their patients quite well. In fact, they may become the member of the team most familiar with all aspects of the patient’s history and current care, most familiar with the patient as an individual, often even meeting their family, and may become a source of support and information to the patient and family. In short, they “bond” with their patients. Because these are the first such experiences for medical students, these relationships can be quite significant for them, and very memorable. Most practicing physicians can recall with considerable detail and deep feeling patients they encountered as medical students.

When a patient assigned and followed by a medical student dies, it can therefore be quite an emotional experience for the student. They can experience a sense of very personal loss. They grieve. When that death occurs as a consequence of the medical illness under treatment, that loss and associated grief are difficult but valuable components of the learning experience. They understand that this is something that every physician must learn to deal with. Doing so is a part of professional development that must be experienced. In the learning context, senior members of the team can support them by sharing the sense of loss and their own experiences. Within the medical school environment, they can also seek help from knowledgeable and experienced advisors and counselors.

Medically assisted death brings new dynamics and challenges to physicians involved in the care of the patients.

Although always prepared intellectually for the eventuality of death as a consequence of illness, students (and qualified physicians) are not prepared either intellectually or emotionally for the concept of deliberately ending a patient’s life, even if they’re not directly involved in the final act. Coming to grips with this in the abstract is one thing, but encountering it in a person one has engaged as a patient and has gotten to know personally is quite another. No one engages medicine as a career with this purpose in mind.

We teach and practice that medical care should continue throughout a patient’s life, and that compassionate attention and care to a patient’s needs and comfort should not stop when cure is no longer possible. Participation in MAID seems, for many, very difficult to reconcile with that approach, even when carried out at the request of the patient.

Medical students on clinical rotations who have been involved with MAID situations, I’ve come to learn, are particularly vulnerable. There are a number of reasons for this. They may be reluctant to express and undertake “conscientious objection” out of fear of being seen as weak or inadequately trained. They may not be aware of that option. They may not yet be clear about their own perspectives on the issue or reactions to these situations. They are young, and for many these may be their first experiences with professional or personal loss. The playing field, therefore, is far from even.

Moreover, supervising physicians and residents who are themselves engaging MAID for the first time may be coming to grips with their own involvement and therefore uncomfortable and unprepared to counsel students involved in these situations.

For all these reasons, we need to give some consideration as to how we can best support students as they (and we) come to grips with MAID. This will involve ensuring:

  1. They understand the legislated rights of patients
  2. They understand the ethical/professional obligations of physicians
  3. They understand the procedures in place to provide MAID in their hospitals and communities
  4. They learn of the needs and how to best support patients with chronic pain and other end-of-life challenges
  5. They understand that when patients under their care die, they will experience a personal reaction they won’t be able to fully anticipate until it happens.
  6. That they know how to seek help to deal with these situations.

We also need to ensure our residents and faculty are aware and prepared to respond.

 

There is a danger that raising such concerns may be regarded as callous to the suffering of patients with terminal diseases, or opposition to their right to choose an option that is legally available to them. That is not the intention. The right to assisted death has been legally provided and should be honoured. However, the well-intentioned efforts to provide MAID has placed new and impactful demands on physicians and learners which were either unanticipated or ignored. We must consider these consequences as we come to grips with how this legislated right is to be provided.

In the end, there is something profoundly dissonant about expecting that those who have dedicated their lives to preserving life will also participate willingly in ending it, and without personal consequence. There is a price to be paid, and that toll may be falling on the most vulnerable among us.

 

Anthony J. Sanfilippo, MD, FRCP(C)

Associate Dean,

Undergraduate Medical Education

11 Responses to Unintended casualties of Medical Assistance in Dying

  1. Chris Smith says:

    Tony

    Thank you for your thoughtful comments as usual.
    It is not just the residents and medical students though who are experiencing this for the first time.
    I have just been involved in my first case of a patient requesting MAID and I must admit to feeling very conflicted in my emotional reaction. There is a dissonance in the care which I have not experienced before and still trying to process how I feel about it

  2. Craig Goldie says:

    Hi Tony,

    Thanks for your eloquent thoughts on the issue. The palliative care community is struggling with this as we are often engaged closely with patients who ask about, consider, or request and receive MAID. Although palliative care is distinct from MAID, we certainly spend a large amount of time with patients who are suffering, families who are suffering, and indeed sometimes health care providers who are suffering with a patient with advanced illness and irreversible decline. I will say that my experience and comfort with natural death (from advanced illness or even withdrawal of life support) has not translated to the same feelings for death via euthanasia (MAID) which is becoming more prevalent as we approach 1 year into legalization.

    Our learners (and attending staff) are all struggling to reconcile personal beliefs, biases, and understanding of suffering with the new reality of MAID. We struggle mightily when we feel the health care system is not able to provide adequate palliative care to manage a patient’s suffering, or that our society does not accept and support aging, debility, and death very well. We try to support our learners with their feelings and the myriad of coping strategies that can be used to help learners not experience burnout or compassion fatigue or other negative thought processes including depression and suicide.

    It is very important to check in with our learners, particularly our clerks, as they are often self-conditioned to suppress their emotions and struggles in order to appear “professional” and aloof. I think it’s also important for our residents, fellows, and attending physicians to freely express our grief and other emotions and to show it’s important to allow our reactions to come out (in healthy ways) and seek help. Queen’s Medicine has Student Affairs which include confidential Wellness Advisors who are practicing physicians who can help medical students and residents who are struggling. There is also a counsellor through Student Wellness Services. Attending physicians can access help through the OMA Professionals Health Program.

    If we see someone who appears to be struggling, for any reason, we should help them and support each other with MAID but also all the other difficult things that physicians have to deal with every day.

    I appreciate you posting about a difficult topic that we are all still learning to manage.

    • Thanks Craig, for those insightful comments. As you note, we have a number of options in place to help student navigate these clinical situations, but will be having discussions soon to explore new approaches to the particular issues raised by MAID.

  3. Ray Viola, MD, Palliative Medicine says:

    Today’s Canadian medical students will not know professional health care practice that does not include the legal availability of professionally-hastened death. Prior to June 2016, physician teachers in Canada never experienced health care that included legally available professionally-hastened death. We now have the responsibility of teaching and role-modeling patient care and physician practice with this new reality in Canadian society while we try to understand and incorporate the reality ourselves. I believe that open and respectful discussion with health care professional colleagues, including trainees at all levels, is necessary to help us all learn from our experiences. The next generation of physicians need this from us.

  4. Claudio Soares MD PhD FRCPC MBA. Professor of Psychiatry at Queen's University says:

    Thank you for sharing this….quite timely as I was addressing the exact same topic this morning in a meeting with our Chief of Staff at KGH. Psychiatry will likely have its own share of unintended exposure to MAID. We need to brainstorm the best way to prepare our residents and mental health professionals to properly handle (with compassion and professionalism) ‘ casual or incidental’ MAID requests expressed at ER or during Psych Consultation-liaison requests- particularly in the context of overdose, suicidal attempts……

  5. Karen Schultz, Queen's Family Medicine Program Director says:

    Thank you Tony….as always I enjoyed reading your blog. 2 of our faculty (Susan MacDonald and Sarah LeBlanc) and one of our residents (Danny Zimmerman) have done research in our department exploring a number of issues to do with MAID with our FM faculty and residents. One of their many interesting findings was the number of faculty and residents who feel uncomfortable/unsafe discussing that they are conscientious objectors–it is a significant number. If this is true of preceptors and residents it must be all the harder for medical students. Literature from the Netherlands has shown that without respectful communication between team members about differing points of view about MAID there is a real danger of disrupting a previously well functioning team. It is a serious issue that we will need to pay deliberate attention to as things evolve with MAID.

  6. Andrew Robinson says:

    As a physician who has been involved in a number of MAID cases, and I’d argue a” ‘conscientious supporter”, I definitely see a need for house staff and medical staff to be prepared/educated. There are many challenging deaths in both expected/unexpected ways in medicine that we have all experienced – some “unsettling”, and some where continued suffering is unsettling. Death, as a whole, is something all patients face, and all Medical professionals experience, but rarely talk about – likely for fear of seeming “calllous” or “weak”.

    There are many things I personally find unsettling and dissonant in medical practice. Assisting patients who are suffering end their life with dignity is not one of them, and certainly not contrary to any medical ethics of autonomy/beneficence/non malevolence etc that I ascribe to, but I do understand other physicians may feel differently, which is why effective referrals to non conscientous objectors is required.

    • Thank you Dr. Robinson, for that perspective. I think we can agree on the need for appropriate education and preparation of learners, as well as the benefits of open and respectful discussion about this challenging issue.

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