00:01
So let's think about
medical aid and dying
and what the clinician should do
in responding to a request
by a patient for assistance.
00:10
First and foremost,
the clinician should be
respectful, sensitive,
compassionate, non-judgmental,
hear the person out for why
they're desiring this hasten death.
00:23
Going to be lots of strong
emotions in suffering
tied to why they are
making this request.
00:30
So respond emphatically.
00:32
And that's another
way to strengthen
the therapeutic relationship
with that person.
00:38
Really tried to determine
the nature of the request.
00:41
So why are they asking for this?
Is it just something that
they're contemplating,
something they want to know
whether or not it might be
available in the future,
they really don't have a plan.
00:50
They don't have an
intention to pursue it.
00:53
But they're just exploring it,
to find the nature
of the request,
and again, why they
might be pursuing it.
01:02
And that means using
open ended questions
to understand their concerns,
what have been the things
that are sort of leading them
to make this request?
Are they suffering in some ways,
there's some way that you can
help alleviate their suffering.
01:17
There may be situational factors
that are driving them to this,
maybe there's some
family dynamics
that might be contributing
to their suffering
and having them think
about assistance in dying.
01:28
So there might be ways to
think about the situation,
to figure out ways that you might
help to remediate the situation.
01:36
You really need
to make sure that
you're attending to their
palliative care needs.
01:40
So whether there's pain or
other physical symptoms,
whether there's depression,
whether there's anxiety,
making sure you identify
and manage those adequately
as a means of responding to
this request for assistance.
01:53
And that might require getting
in additional colleagues,
sometimes there needs
to be some brainstorming
about how to best manage a
person's intractable suffering.
02:02
So hopefully, there would be the
use of palliative care clinicians,
others with expertise,
psychiatrists and others,
maybe chaplains to help if
it's existential suffering,
but enlisting these colleagues
to help the person
with their suffering.
02:17
So let's talk a little bit
about responding to suffering.
02:21
Let's take it out
of the you know,
just thinking about medical
assistance in dying,
and just thinking about a
person that is suffering,
what are our obligations,
what should we be doing for
them in their suffering?
So as I've said, we should need
to identify and characterize
what are the problems that
lead to their suffering.
02:40
We really need to be curious
about their experience,
we need to enter their world,
we need to be present to them.
02:47
We need to bear witness
to their suffering.
02:50
And we really need to have
compassionate solidarity
with their suffering.
02:53
We need to enter their world
to know what their
suffering is all about.
02:58
What is the meaning
of the suffering
for them as an individual?
We really need to help patients,
you know, hopefully refocus
and reclaim their meaning.
03:09
So we need to help them try
to figure out make sense of
their illness experience.
03:15
In whatever way we can
provide hope to a person,
you know,
the hopelessness is another
means of getting to suffering.
03:23
So instilling hope, even if it's
no different definitions of hope,
that is a means of responding
to their suffering.
03:31
We need to try to help
support a patient to adapt,
hopefully thrive despite whatever
adversity they're going through.
03:40
Very much, you know, suffering
is threatened identity,
you know, so the person feels
that they have lost who they are,
they've lost meaning.
03:49
So the job of the clinician
when a person is suffering,
is to help that patient regain,
or maybe even reframe
their identity,
figure out who they are,
what's meaningful in their life,
to try to get rid
of that suffering.
04:06
So thinking about
that, just in general,
as we take care of
patients, wherever they are,
you know, from health to
illness, if they're suffering,
how we need to respond to it,
for those particular patients
that might make these
requests for assisted dying.
04:21
There are some responsibilities
we have as clinicians.
04:25
So first is, you know,
even where the places
where it is legal,
the clinician can decide whether
or not they're going to participate
with the patient in the
assistance in dying.
04:36
So the clinician may
decide to act or not act
as an exercise of
their own conscience.
04:45
Second, all clinicians
should ensure that
the patient can
count on good care,
good palliative care,
good treatment of physical
and psychological symptoms,
attention to their suffering,
that should be expectation
for all patients
and clinicians should follow
through on that responsibility.
05:05
The clinician really should
uphold the primary goal
of working towards mutually
acceptable solutions
to the patient's distress.
05:13
So working with the patient,
I said, that's why
you need to be open
and non-judgmental when a
person makes this request
that figure out what
you're willing to do,
what they're willing to pursue,
try to work together to find
mutually acceptable solutions.
05:32
We should always do
our job to prevent
or relieve suffering
insofar as possible.
05:37
So there may be
intractable symptoms
that just are not remediable
to excellent palliative care.
05:45
Again, our job is to try
to do it as best we can
to relieve their suffering.
05:53
All clinicians should have
an unwavering commitment
to human dignity at the
end of a patient's life.
05:58
I personally would
define dignity
not in terms of whether or not
you're incontinent
of stool or urine,
but there's an inherent
dignity in all people
that we should uphold,
even if they are dependent
in bed bound and need care.
06:15
And the clinician
should provide support
to the patient's
family and friends,
both in the dying process,
if there is this decision
for assistance in dying
and the patient follows
through with this.
06:27
There's going to be
bereavement process.
06:29
So the clinician should be there
for the patient's
family and friends
as a manifestation of their
care for the patient as well.
06:38
So medical aid in dying
is a controversial topic.
06:41
It's only available
in a dozen countries.
06:45
It's something
that may or may not
be available where you are,
you should check
your own jurisdiction
about what's permissible
or not permissible
and weigh for yourself,
you know, the pros and the cons
of this option for
certain patients
when they have
intractable suffering.
07:01
So those are some of the issues
that we need to think about,
especially for patients
toward the end-of-life,
whether it's nutrition,
whether it's pain management,
other symptom management.
07:11
Whether there may be the
desire for hasten death.
07:14
All of these things,
really call on the clinician
to work with the patient
to really try to
serve their interests
and figure out how to best
to relieve their suffering
as they near their
dying process.