Physician-Assisted Dying: Most Patients Have Cancer

Roxanne Nelson, BSN, RN

May 24, 2017

Last year, Canada joined a small but growing number of countries and US states in legalizing physician-assisted dying.

A new paper, reporting on the experience to date at a large healthcare system in Toronto, Ontario, found that three quarters of patients inquiring about the program had cancer, and for various reasons, only 26% actually received the intervention.

The paper is published online May 25 in the New England Journal of Medicine.

The degree to which physician-assisted dying has become "normalized," both in their network and throughout Canada, "was unexpected," especially considering the degree of controversy that preceded passage of the law, note the authors.

"This is a radical departure from what we consider the norm for physicians," said lead author, Gary Rodin, MD, Joint University of Toronto/University Health Network Harold and Shirley Lederman Chair in Psychosocial Oncology and Palliative Care. "So there was a lot of caution and apprehension from physicians."

In an interview, he explained that the push for this law did not come from the medical community but from advocacy of the public at large. "That is what has made us feel more comfortable," he said. "Because we are focused on the values of the patient."

Just as advocacy from outside mainstream medicine brought palliative care "from the margins to the center," it has also "brought MAiD [medical assistance in dying] into the mainstream of medicine," the authors write in their paper.

It is now being implemented in a major clinical center. Dr Gary Rodin


And it is mainstream, Dr Rodin reiterated. "It is now being implemented in a major clinical center, it is happening. The public accepts this as an option to end-of-life care, and mostly, people want a plan B if things get too difficult."

MAiD was decriminalized by the Canadian Supreme Court on February 6, 2016, and was followed by legislation in June 2016, which specified the conditions under which MAiD could be legally provided. Upon passing this law, Canada joined five European countries (the Netherlands, Belgium, Switzerland, Germany, and Luxembourg) and six US states (Oregon, Washington, Vermont, Montana, California, and Colorado), as well as Colombia, in all of which physician-assisted dying has been legalized in some form.

Fears Unfounded

The topic remains highly controversial, even though some surveys show growing acceptance among physicians. One of the fears of implementing such laws has been that disadvantaged patients would be disproportionately affected by it and that this type of law would open up a proverbial slippery slope. There is concern that once it is permitted for terminally ill patients, the rules could then easily become less stringent and begin to include other populations.

However, as previously reported by Medscape Medical News, data from Oregon, which has had an assisted dying law in place for 20 years, show little evidence of any sort of abuse or misuse.

Experience at UHN

The Canadian experience is only a year old, and in this paper, Dr Rodin and colleagues report on how MAiD has been implemented to date in their healthcare system.

Unlike US regulations, the Canadian MAiD law allows either assisted suicide or euthanasia by injection. A hospital-based MAiD program exists at the University Health Network (UHN) in Toronto, which is composed of 4 tertiary care teaching hospitals that collectively provide care to nearly 40,000 inpatients and supports over 1.1 million ambulatory care visits per year.

At UHN, MAiD is limited to intravenous administration of lethal medications within the hospital setting. In contrast, in Oregon, the procedure involves patients being prescribed oral tablets, which they then take at home.

Dr Rodin said that their center chose intravenous administration because their system is largely hospital based, it is faster, and there are fewer associated complications.

To circumvent conscientious objection and the personal discomfort of some staff, involvement in MAiD is purely voluntary.

"We have a specific team who does the assessment and a team who does the intervention," he said. "So conscientious objection is not an issue with our program."

Patients began to inquire at UHN soon after assisted dying was decriminalized, and the current paper covers the period from March 8, 2016, to March 8, 2017.

A total of 74 individuals inquired about MAiD during that time period, of whom 74% had been diagnosed with cancer. Other conditions included neurologic disorders (amyotrophic lateral sclerosis, stroke, neurofibromatosis, multiple sclerosis, cortical basal degeneration, myasthenia gravis, and Parkinson's disease) and lung conditions (chronic obstructive pulmonary disease, bronchiectasis, and interstitial lung disease).

Within this group, 29 patients (39%) went on to be assessed. The reasons for not proceeding were varied, including withdrawal of the request by the patient, primary mental illness, delirium, and death. Most of the patients who underwent assessment were approved for MAiD (86%; n = 25), and 97% were already receiving specialty palliative care services.

At the cutoff date for this analysis, 76% (19 of 25) had received MAiD, and reasons for not proceeding included natural death in some cases or a change in the patient's decision.

"Patients must be able to give informed consent, and if their condition changes and they are unable to do so,  then they are no longer eligible," explained Dr Rodin.

Individuals receiving MAiD tended to be white and relatively affluent. "As has been reported elsewhere, most patients did not cite pain as their primary reason for doing this," said Dr. Rodin. "Their main reason was loss of autonomy and wanting a sense of control over dying."

Their main reason was loss of autonomy and wanting a sense of control over dying. Dr Gary Rodin


Other reasons given were the desire to avoid burdening others or losing dignity and the intolerability of not being able to enjoy one's life.

The authors add that "it is now clear that MAiD education must be included in undergraduate medical education curricula in Canada and in the training for a variety of specialties, including general medicine, family medicine, oncology, neurology, respirology, palliative care, pharmacy, psychiatry, social work, spiritual care, and bioethics."

The authors have disclosed no relevant financial relationships.

N Engl J Med. 2017;376:2082-2088. Abstract

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