Physician-assisted death is legal in Canada, but the country is still struggling to provide end-of-life support to those who need it
When John went into a Mississauga emergency department in August, he knew his days were numbered.
Fiercely private, frail but stoic, the 65-year-old man had kept the signs of his failing health hidden from almost everyone until he couldn’t manage it anymore.
“I stayed in my apartment and only went out in the middle of the night — I didn’t want people to look at me and feel pity,” he told me. “I knew I was dying. But I hate hospitals; I always have. So I waited until I had no other option.”
John went to emergency only because he wanted to request medical assistance in dying, which the federal government had recently legalized. After researching his symptoms online, he had (correctly) diagnosed himself with pancreatic cancer and determined that his treatment options were limited.
His sister, Susan, says navigating the assisted-dying process was challenging. “I read everything the province put online — we thought we were well informed,” she explains. “But when we got to the hospital, we were going through this myriad of possibilities, and there were several unknowns.”
John died in September, shortly after he was approved for assisted death. But his death was not physician-aided — he spent his final days in a palliative care unit. And so, too, will many others who have requested to die. According to a report released by the Canadian Society of Palliative Care Physicians (CSPCP) in November, only one of every six patients who ask for medically assisted death will be approved. Most of the 62,400 people projected to request it in 2017 will receive palliative care instead.
But Canada is already having difficulty providing palliative care to those who need it, even without factoring in the surge in patients asking for medically assisted death. Just 30 per cent of the 260,000 Canadians who die each year have access to palliative care. And many, like John, are given access only a few days or weeks before they die.
In a report published this year, Health Quality Ontario said this province does no better than the rest of the country. Most Ontarians die in hospital, and the majority don’t access palliative care until their last two months of life. In order to meet the needs of those seeking medically assisted death in the next year, Ontario would have to double the number of practising palliative care specialists.
Canada could look to Belgium for some pointers. Before 2002, when physician-assisted death was legalized, the Belgian government doubled spending on palliative care, and funding has increased more than 10 per cent every year since. Its decision to boost support was based not only on the merits of palliative care, but also on the belief that assisted death would be unethical if it were carried out because of a lack of access.
Although Belgium has been criticized for expanding its assisted-death legislation to include children and those not terminally ill, it has successfully integrated palliative supports and assisted dying so that all patients requesting the latter receive the best possible care. The increase in palliative services benefits all patients, not just the ones asking to die.
In Canada, federal health minister Jane Philpott plans to inject $3 billion into the next budget to help advance both home and palliative care access for Canadians. But David Henderson, president of the CSPCP, says that’s not enough. “Prime Minister Justin Trudeau and Health Minister Dr. Jane Philpott must do more,” he said in a statement in November.
The government, he added, has also failed to propose an implementation plan or make a clear commitment to universal access. And now that Canadians are guaranteed the right to medical assistance in dying, ensuring universal access to palliative care is essential.
In its 2016 budget, Ontario added an additional $75 million over three years to provide patients with more options and access to community-based palliative care. But it may be a while before patients see change on the front lines. According to the Ontario auditor general’s annual report, released in late November, none of the palliative care recommendations issued by the office in 2014 have been fully implemented, and on 40 per cent of them, no progress has been made at all.
For John’s family, helping him navigate his options was the top priority. “A patient doesn’t know when they are dying … when they are going to go into unbearable pain. It’s tough to help them make decisions,” Susan says. “Palliative care was wonderful. He had their care from the second day we were in the hospital. One of our fears was that they wouldn’t let him in the palliative care unit if he said he wanted medical assistance in dying. If they could be integrated, how wonderful would that be?”
“The main thing is I don’t want to suffer,” John told me a few days before he died. “I’m gravely ill. In fact, I’m dying. If I knew right now that I would be at peace — no pain, no breathing problems, just slip away — that would be great.”
Seema Marwaha is a physician at Trillium Health Partners and a fellow in global journalism at the University of Toronto’s Munk School of Global Affairs.