Responding to Requests for Medical Aid in Dying

by Mark Hughes, MD, MA

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    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.

    About the Lecture

    The lecture Responding to Requests for Medical Aid in Dying by Mark Hughes, MD, MA is from the course Ethical Considerations in Palliative Care.

    Included Quiz Questions

    1. Use close-ended questions
    2. Respectful, sensitive responses
    3. Empathetic responses
    4. Determine the nature of the request.
    5. Explore situational factors
    1. Decide to act or not to act.
    2. Ensure that the patient can count on good care.
    3. Work toward a mutually acceptable solution.
    4. Prevent suffering as much as possible.
    5. Support the patient's family without a commitment to supporting the patient's friends.
    1. Arrange for funeral proceedings.
    2. Decide to act (or not act) as an exercise of conscience.
    3. Ensure good care.
    4. Work toward a mutually acceptable solution.
    5. Prevent or relieve suffering.
    1. Help a patient refocus and reclaim their meaning.
    2. Help a patient discard their identity.
    3. Leave the patient alone.
    4. Ask colleagues to avoid discussing patient suffering.
    5. Redirect conversations about end-of-life care.

    Author of lecture Responding to Requests for Medical Aid in Dying

     Mark Hughes, MD, MA

    Mark Hughes, MD, MA

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