Preparing for physician assisted dying

Most of the Canadian public is likely not aware that Canada is on the precipice of legally allowing physician assisted dying (PAD). The Quebec legislature has already passed a bill that will take effect in late 2015 to allow doctors to help a patient end his or her life. The Supreme Court of Canada heard a case this week from British Columbia regarding the legality of PAD.

It is apparent that in the very near future, PAD will be a reality in Canada. This post is not about the ethics or morality of this legalization; however, I will be upfront about my bias in that I believe in equal and open access for terminally ill patients to die with dignity, while respecting others’ opinion against “euthanasia” (a term that is being appropriately phased out) for moral, religious, or any other reasons. My opinion is anything but radical as 84% of the Canadian population and 85% of healthcare professionals support PAD. With a large amount of evidence from Europe, Vermont and Oregon showing that assisted dying does not take advantage of vulnerable populations, this decision should (and hopefully will) be guided by the wishes of our society as a whole.

As a side note, can we all please stop saying that all we need is better access to palliative care, and that that is a reason to not legalize PAD? The claim that only 16-30% of Canadians have access to palliative care has been thoroughly debunked, and palliative care has improved in countries and states that have passed laws to allow physician assisted dying. And despite the best palliative care in the world, some patients still suffer debilitating symptoms near the end of life and seek PAD. Of the 32,475 deaths in Oregon in 2012, 85 were via physician assisted dying.

Where do oncologists come into play within the realm of PAD? Due to the sheer incidence of cancer, a large proportion of terminally ill patients are under the care of oncologists. Therefore I believe that we (oncologists), along with our colleagues in palliative care, will need to educate the public on their options regarding end of life care and PAD. We should also take a lead role in helping to educate all other physicians regarding how to navigate this new system that will have significant (and appropriate) checks and balances before patients can pursue PAD.

It is possible that oncologists, particularly in more remote regions, may be called upon to provide assisted dying (I cannot find data from the USA regarding which types of doctors have been providing the prescriptions to facilitate PAD). Oncology-related residency programs will therefore need to provide basic education on the technical and emotional aspects of PAD. Training in fact should be initiated widely across all medical specialties since it will be better for patients who choose PAD to have access locally rather than forcing them to travel or move (along with their families) to another city at the late stages of their illness. When Canada legalizes PAD there should be a national strategy and unifying national law so that we avoid the situation (like in the USA with Oregon) where patients are moving to a new city or state in order to obtain access to PAD.

In the next few weeks, the already contentious debate regarding PAD will reach a climax, since this is a topic that many people feel quite strongly about. What should not be lost amongst the debate is the necessary strategy, training and infrastructure required to provide this service (once legalized) in the most humane way possible.

Choosing primary care: why is Canada different than the US?

It is a slow night on call at the hospital, and I came upon an excellent article called “Why I’m becoming a primary-care doctor” in which a medical student at the University of Pennsylvania discusses her choice to enter a family medicine residency. I was shocked at two aspects of the story: first, that only 12% of graduates in the US residency match ended up in primary care specialties, and second the disdain which the author feels many of her classmates and some of her preceptors have for family medicine.

In Canada in 2013 (the year I matched to residency), 37% of all graduating medical students matched to family medicine as their top choice of programs. Where I trained, at the University of Toronto, home to some of the most highly sub-specialized programs and staff physicians in the country, 33% of students chose family medicine as their top choice. And that doesn’t include pediatrics, from which many graduates will go on to become primary care pediatricians. (In Canada, internists are not generally considered primary care doctors, in contrast to the US).

In terms of attitudes, I have personally never heard any classmates, residency colleagues, or staff doctors echo the sentiment that “on family medicine, the intellectual rigor is not there”. And this article made me wonder what is fundamentally different between Canada and the US systems whereby primary care medicine is viewed so differently. While I cannot claim to know the answer, I have some hypotheses I would like the throw out there.

Many of the academic (and community) hospitals in Canada have family care practices based physically at the hospital (or close by). This fosters stronger relationships between subspecialists and family doctors. If a complete separation between family doctors and hospital-based specialists occurs, there is a greater risk of one group looking down on the other. And since in the US the differential in salaries between specialists and family doctors is enormous, it is not surprising that the general public, and the specialists themselves sometimes think that “a monkey could [practice general medicine]”. Also, since historically one-third to one-half of medical students go into family medicine in Canada, I would presume nearly all Canadian doctors have friends in the specialty and gain an appreciation and understanding for the job they perform.

During my time on the general internal medicine ward, anytime a patient was admitted with a complex medical history or in whom the diagnosis was unclear, my first act the next morning was to personally speak to the patient’s family doctor to gain further insight into the issues at hand. And every time I discharged a patient, I instructed them to see their family doctor the next week so that their GP knew what had happened to them, and to make sure the patients were coping well at home. I have no data to back this up, but I believe patient care is better because patients have access to excellent family doctors that provide continuity of care.

Overall I am glad that I work within a system with a strong and well-respected force of primary care physicians fostering long term relationships with their patients, treating a wide range of illnesses, and taking charge of preventative care where some of the biggest gains in the health of our population can be achieved.