CANADIAN
PROVINCES
CREATE END-OF-LIFE
HEALTH-CARE LAWS
The Supreme Court of Canada has opened the way for new end-of-life
laws
by overturning the old 'assisted suicide' criminal law on February 6,
2015.
Generously, the justices in their unanimous ruling
gave the national Parliament of Canada one year
to create a new criminal law to replace the old, defective law.
In January 2016, the Supreme Court of Canada
extended this deadline by four months—to
June 6, 2016.
A new House of Commons was elected in October
2015.
In April 2016 Bill C-14 was introduced to fill the gap.
After some modifications by both houses of Canada's Parliament,
it became law in June 2016: Medical
Assistance in Dying (MAiD).
This law continues to prohibit 'assisting suicide',
but it makes explicit exceptions for physicians and nurse practitioners
to prescribe and/or provide gentle poison for their dying patients.
In Canada, the Criminal Code is created by the
national legislature.
But health-care regulations are left to the provinces and
territories.
And
provincial organizations of doctors
have created their own guidelines
for recommending end-of-life medical decisions for their patients.
Even before the Supreme Court ruling,
the
province
of Quebec had already created its own new end-of-life law.
This law authorizes three medical methods of managing dying:
(1) withdrawing life-support systems and curative medical treatments;
(2) "continuous palliative sedation"---inducing a coma
lasting until
death; &
(3) "medical aid in dying"---giving the patient gentle poison to cause
death.
When other provinces create any new end-of-life
legislation,
they can be as explicit and detailed as they please
in defining what end-of-life medical treatments are permitted.
Such end-of-life medical care
will no longer conflict with the Canadian Criminal
Code.
Much can be learned from reading the Quebec
end-of-life law,
but it can also be improved in a number of important ways.
Legislators creating new health-care rules and
regulations
for anywhere else on the planet Earth
can also adapt the following provisions for their own jurisdictions.
FIVE MEDICAL METHODS OF
MANAGING DYING
CAN BE
OFFICIALLY AUTHORIZED
Quebec named only three specific
medical methods of managing dying.
But the other two are not against the law anywhere,
so it would do no harm to name them explicitly
in any new laws created by any of the provinces of Canada.
When all five methods of managing dying approved by
doctors
are explicitly written into the health-care law of any province,
then patients and their doctors can choose any combination
that fits any particular patient and family.
The new end-of-life health-care law
can officially and legally authorize dying patients and their families
to choose the best pathway towards death,
using the most appropriate of the following
five medical methods of managing dying.
(Links
from these methods lead to more information on the
Internet.)
1. COMFORT-CARE
ONLY
When the patient is already receiving pain-meds from
the doctor,
the doctor can order an
increase in these symptom-contolling methods
with an explicit awareness that giving more drugs
will probably shorten the
process of dying.
Adjusting the levels of pain-killers
is already within the normal practice of medicine everywhere.
And professional standards of terminal medical care
establish the reasonable limits of such increased medication.
This method of dying should not be confused with
giving a intentional overdose of drugs
with the purpose of causing immediate death.
Immediate death by drugs is approved method 5, below.
2. INDUCED
TERMINAL
COMA
If the patient's symptoms cannot be satisfactorily
controlled
by increasing the pain-medications already in use,
then the patient (and/or the proxies) and the doctors
can select another medical method of managing dying for this patient
—continuous,
deep sedation until death comes from natural causes.
Drugs will be given (and adjust as needed)
to guarantee that this patient will be kept completely unconscious
while the rest of the dying process unfolds as expected.
As with all other medical methods of managing dying
(such as increasing pain-medication and disconnecting
life-supports),
the cause of death
will be recorded as the underlying disease or condition.
3. ENDING
CURATIVE TREATMENTS AND LIFE-SUPPORTS
Also completely within the normal practice of
medical care,
the patient and/or the proxies can agree with the doctors
to discontinue whatever medical supports are keeping the patient alive.
As medical technology becomes a common
part of terminal care,
it will also become more common for life to end
when the various systems of supporting vital functions
are disconnected or discontinued because they are doing no good.
4. VOLUNTARY
DEHYDRATION
Often one of the forms of life-support was a
feeding-tube,
which was keeping the patient alive by artificial nutrition and
hydration.
When other life-supports are switched off,
water provided by any method is usually also discontinued.
The patient will not benefit from having more food and fluid.
But this way of managing dying can also be
authorized
when there are no other major life-supports in place.
And here, as with any other medical methods of managing dying,
careful
safeguards must be fulfilled
to make certain that giving up fluids is a wise way to manage dying.
5. IMMEDIATE DEATH BY DRUGS
This new authorized medical method of dying
(beyond what was already common in modern medical care)
will allow a physician to prescribe lethal chemicals
with no other purpose in mind beside
to grant the patient a speedy and painless death.
When this method of dying is the primary means
by which a patient's life will come to an end,
then the others methods of dying become irrelevant.
But the other methods of getting ready for death
might have been chosen as
preparation for this final act.
For example, water might have been given up some days before
because it only caused the patient to suffer more deeply.
Also, the patient might be unconscious
as the result of drugs already given as part of the terminal care.
Either the patient himself or herself or proxies for
this patient
can authorize this shortest medical method of dying.
The specific method of administration of this fatal
dose of drugs
will depend on the exact situation of the patient at the end of life.
Such details might (or might not) be specified in any new end-of-life
law.
Safeguards ensure that this
is a wise life-ending
decision.
Then the particular methods
of dying will not be as important
as achieving the desired, planned, & authorized result
—immediate
death for this patient.
EIGHTEEN BEST SAFEGUARDS FOR
LIFE-ENDING DECISIONS
The core of any new end-of-life medical care act
authorizing these five medical methods of managing dying
will be a set of careful safeguards
to be fulfilled by the patient, the family, & the doctors
before the plans for death go forward.
All end-of-life laws do have implicit and explicit
safeguards,
but a major problem with the earlier laws
is scattering the safeguards thru-out the body of the
law.
This means that people attempting to follow the law
must read the whole law (or some organized summary of the law)
in order to discover if they have fulfilled each and every safeguard
intended by the law-makers when
they authorized
the above medical methods of managing dying.
Because several different people will be consulted
in making this life-ending decision,
we should not expect them all to read and sign the same statement.
The safeguards should all be stated and explained
in one easy-to-find section of the end-of-life law.
These safeguards should be named and numbered (or lettered)
so that a check-list can be created to make certain
that all of these important documents have been completed and
recorded.
Each province might select a slightly different set
of safeguards.
This is the consequence of having provincial
in addition to national
regulations concerning end-of-life choices.
The following list of possible safeguards
is organized beginning with the most important.
Provinces that wish to have a very careful system
for authorizing end-of-life choices
will incorporate all
of these suggested safeguards
—and
they might even create a few additional safeguards.
Provinces that feel less need for details
will select from the first few safeguards.
In your province, which safeguards would be the most
useful
for the purpose of preventing
irrational suicide
and other forms of premature
death?
Because these safeguards are concerned with
health-care
rather than criminal law,
safeguards assigning punishments for outlawed behavior
should be left to the national Parliament.
These safeguards are
selected from the more complete list of
safeguards for life-ending decisions included in
How
to Die:
Safeguards for Life-Ending Decisions.
And they retain their letters from that list of 26 safeguards.
Each safeguard is linked to a complete explanation on the Internet.
Safeguards for making life-ending decisions
should be written in soft ways
so that patients, their families, & their doctors
will not first think of ways to avoid or ignore the safeguards.
Governments should not close the gate and establish gatekeepers
in order to limit making wise end-of-life medical decisions.
This will only make the patients and their doctors angry at government.
Wise safeguards will provide operational
methods
for examining all remaining end-of-life options for medical care.
Likewise, safeguards should not give exclusive power
to doctors
to say "no" to patients' requests for help in dying.
Rather, the safeguards should function as creative
ways
to empower the decision-makers to separate
premature death from death at the right time.
End-of-life situations that were unclear or uncertain initially
can achieve consensus among the deciders
by the process of carefully fulfilling the following safeguards.
A. ADVANCE
DIRECTIVE
FOR MEDICAL CARE
A written statement explaining the patient's
philosophy of life and death
is probably the most basic document for making end-of-life decisions.
Life belongs to each individual patient.
His or her settled values
should shape all medical decisions.
For an overview of what a comprehensive Advance
Directive should cover,
see Advance
Directives for Medical Care: 24 Important Questions to Answer.
Once the patient has created an Advance Directive
for Medical Care,
he or she will share the Advance Directive with significant others
—especially those
chosen as proxies.
And the proxies should create brief statements
expressing their agreement with
the Advance Directive
and their commitment to carry forward
the settled
values of the patient.
B. REQUESTS
FOR
DEATH FROM THE
PATIENT
The patient owns his or her own life and death.
Whenever the patient is still capable of making medical decisions,
any and all serious requests for death should be recorded,
stating the date, time, circumstances, & witnesses.
The patient should also explain why he or she thinks
death at the chosen time
would be better than death
at some later time.
Such requests for death might lead to creative discussions
among all the people concerned with this patient's life and death.
If the patient is no longer capable of making
medical decisions,
the duly-authorized proxies then have the power and responsibility
to make any reasonable requests for death on behalf of the patient.
See Safeguard
K
below: Requests for Death from the Proxies.
C. PSYCHOLOGICAL
CONSULTANT EVALUATES
THE
PATIENT'S
ABILITY TO MAKE MEDICAL DECISIONS
If there is any doubt about the patient's
mental capacities to make medical decisions
—including any
decisions that will terminate his or her life—
then the patient's decision for death should be evaluated
by a licensed psychologist or
psychiatrist.
D. PHYSICIAN'S
STATEMENT
OF CONDITION AND PROGNOSIS
The most important document created by a medical
professional
will be the physician's summary of the patient's condition and
prognosis.
In order to avoid any confusion, ambiguity, or misunderstanding,
this statement should be put
into writing
as well as explained to the satisfaction of those who must decide.
E. INDEPENDENT
PHYSICIAN REVIEWS THE CONDITION AND PROGNOSIS
Whenever making life-or-death decisions,
it is always wise to seek a second—independent—professional
opinion.
This second opinion might be sought from a specialist
in the disease or
condition from which the patient is possibly dying.
If there are differences in these professional opinions,
any such uncertainties should be resolved by further investigation
before the plans for death proceed.
F. CERTIFICATION
OF TERMINAL ILLNESS OR INCURABLE CONDITION
Even tho the patient need not be in a terminal
condition to request death,
if the disease or condition is likely to lead to death,
the same physicians who have written
the full statements of the
patient's condition and prognosis
might also create a separate document to certify terminal illness
if the patient is likely to die within the next 6 months.
Or such certification could be included in the doctors' other
statements.
Certification of terminal illness should specify
whether the projected period of survival includes
life-supports or not.
G. UNBEARABLE
SUFFERING
An important question for any life-ending decision
is whether the patient is suffering in some way that cannot be relieved
and which the patient
finds intolerable.
Such physical suffering can be explained and documented
by the doctors who have been treating the suffering.
H. UNBEARABLE
PSYCHOLOGICAL SUFFERING
The patient might also be suffering emotionally.
Only the patient can ultimately decide whether such suffering is
intolerable.
But professional efforts to alleviate the mental suffering
should also be documented.
Psychological suffering can be evaluated by both family and doctors.
And if the psychological suffering is so great
as to make the patient incapable of making wise medical decisions,
then the power to decide passes to the authorized proxies.
The proxies will make any life-ending decisions:
Is death now wiser
than death later?
I. PALLIATIVE
CARE
TRIAL
The actual application of comfort care
by medical professionals well trained in the care of the dying
will help to decide which is the wisest course of action.
Sometimes physical and psychological suffering can be so reduced
that the patient and/or proxies no longer believe
that death is the best
choice at this time.
However, in some obvious cases, palliative care
would be useless.
But at least the patient and/or proxies should be
fully
informed
about the benefits of palliative care
and even consult with a palliative-care specialist.
J. INFORMED
CONSENT FROM THE PATIENT
The patient must have full information
about his or her condition
and all the possible medical treatments that still remain
open.
When the patient has received and understood the medical statements
from the doctors concerning
condition and prognosis,
the patient is empowered to make wise end-of-life choices.
K. REQUESTS
FOR
DEATH
FROM THE PROXIES
If the patient can no longer make
meaningful medical decisions,
then the decision-making power shifts to the proxies,
who have been carefully selected by the patient
when the patient was still fully able to make all medical choices.
The proxies shall carefully consider all of
the medical facts,
taking into account the opinions of everyone legitimately concerned.
Then the proxies can
decide to make requests for death
in the same ways as such requests were once possible
for the patient.
L. ENROLLMENT
IN A
HOSPITAL OR HOSPICE
If the patient is
being treated in a hospital
or receiving terminal care in a hospice program,
any such medical institution will keep careful records
of all
discussions and decisions regarding the care of the patient
—including all
explorations of end-of-life choices.
Terminal-care professionals deal with life-ending decisions frequently.
They will not support a premature death.
M. STATEMENTS
FROM
HOSPITAL OR HOSPICE STAFF MEMBERS
The nurses, doctors, & volunteers who know the
patient well
can also create statements
about their discussions
with the patient about end-of-life choices.
Do those who see the patient every day agree with the life-ending
decision?
N. STATEMENTS
FROM FAMILY
MEMBERS
AFFIRMING
OR
QUESTIONING CHOOSING DEATH
Other persons who
have known the patient for meaningful
periods of time
either agree with the life-ending decision
or question the wisdom of ending the patient's life now.
Even tho these 'significant other' persons might not be directly
involved
in the process of making any life-ending decisions
and they will not be responsible for carrying out any terminal choices,
they
know of
the
plans for death well in advance.
And they create written statements either affirming the choice of death
or questioning the wisdom of the end-of-life plans.
What are their considered opinions about the proposed death?
Q.
AN
INSTITUTIONAL
ETHICS COMMITTEE
REVIEWS
THE
PLANS FOR DEATH
An ethics
committee of the institution where the patient is receiving care
reviews all of the documents created for the
death-planning process
and approves or questions any life-ending decisions.
The ethics committee should meet with the patient and/or the proxies.
If there is no ethics committee,
a private ethical consultant
can review the plans for death.
R. STATEMENTS
FROM
ADVOCATES FOR
DISADVANTAGED GROUPS
IF
INVITED BY
THE PATIENT AND/OR THE PROXIES
If any patients worry that they might be discriminated
against
because they are members of any group sometimes
disfavored by society,
they can select advocates from their own
identity-groups
who will review the death-planning documents
to make sure that no
discrimination has taken place
because of the group-identity of the patient.
Adding any such statements to the death-planning record
will assure others who are not as close to the patient
that the life-ending
decision was as free as possible from discrimination
and that the patient received terminal care independent
of group-identity.
U. WAITING
PERIODS FOR REFLECTION
Appropriate periods for further reflection are needed
between the time when the first
life-ending decision is made
and when the final
life-ending act
is performed:
(a) one week for the
withdrawal of life-support systems,
(b) one year for a voluntary
death, or
(c) six months for a merciful
death.
These waiting periods may be adjusted when adequately explained
by the special circumstances of the specific patient.
Spreading the end-of-life discussions over significant
periods of time
encourages all concerned to re-think
their previous
decisions.
V. OPPORTUNITIES
FOR THE PATIENT TO RESCIND OR POSTPONE
ANY
LIFE-ENDING
DECISIONS
If the patient has already
begun the death-planning process,
ample
opportunities should be provided
for the patient to change his or her
mind.
The people offering these opportunities should
document
that the patient had several occasions to change the plans for death.
Does the patient decline each opportunity to
change course
and reaffirm his or her determination to choose death?
As said at the beginning, the province of Quebec
has already created its own law
for end-of-life medical care.
It has 17 explicit safeguards, scattered thru-out the law.
These Quebec safeguards are gathered at the beginning
of the above presentation of Quebec's end-of-life law.
This
organized list of Quebec's safeguards is also reproduced below.
Does your province want to adapt the safeguards
already selected by Quebec?
An
Organized list of the safeguards
embedded in Quebec's end-of-life law
The
safeguards in Quebec's law are here organized
from the most important to the least important.
And they keep their letters
from the comprehensive list
in How
to Die:
Safeguards for Life-Ending Decisions.
SAFEGUARD B Requests
for
Death from the Patient
SAFEGUARD
A Advance
Directive
for Medical Care
SAFEGUARD
J Informed
Consent from the Patient
SAFEGUARD
C Psychological
Consultant Evaluates the Patient's
Ability to Make Medical Decisions
SAFEGUARD
D Physician's
Statement of Condition and Prognosis
SAFEGUARD
E Independent
Physician Reviews the Condition and
Prognosis
SAFEGUARD
F Certification
of Terminal Illness or Incurable
Condition
SAFEGUARD
G Unbearable
Suffering
SAFEGUARD H Unbearable
Psychological Suffering
SAFEGUARD
V Opportunities
for the Patient to Rescind or Postpone the
Life-Ending Decision
SAFEGUARD
K Requests
for
Death from the Proxies
SAFEGUARD
N Statements
from
Family Members Affirming or
Questioning Choosing Death
SAFEGUARD
U Waiting
Periods
For Reflection
SAFEGUARD
M Statements
from
Hospital or Hospice Staff Members
SAFEGUARD
X Complete
Recording and Sharing of All Material Facts
and Opinions
SAFEGUARD
AA Information
about
Palliative Care and other Alternatives to Death
SAFEGUARD
DD The
Patient
Must be an Adult Resident of the State
(The residency requirement is
implicit in section 26 (1),
which requires the patient to
have health insurance provided by Quebec.)
By this
count, there are 17
safeguards in Quebec's law:
The smallest number of
safeguards apply to ending
medical treatments
(section 6).
The next larger number of
safeguards apply to continuous
palliative sedation
(section 25),
And the most safeguards are
applied to medical
aid in dying (sections
26-31).
Created
November 7, 2015; Revised 11-12-2015; 12-1-2015; 12-8-2015;
1-21-2016;
3-24-2016; 4-15-2016; 5-25-2016; 6-7-2016; 7-9-2016;
12-10-2018;
links for lawmakers
A
Facebook Group has been established for
Right-to-Die
Legislators.
When
any
member of a law-making body anywhere on Earth
has created a proposal for a new health-care law or regulation
or a law replacing provisions concerning 'assisting suicide',
a link can be offered to this Facebook Group.
Safeguards
for
life-ending decisions
as found in various laws and proposals for laws.
Replacing
Laws
Against 'Assisting Suicide'
How
to Die:
Safeguards for Life-Ending Decisions
See especially PART SIX:
CHANGING
LAWS
CONCERNING THE RIGHT-TO-DIE
Portal
for the
Right-to-Die
Canada's
national law permitting "medical assistance in dying"
This will be the background for any provincial legislation in Canada.
Quebec's
right-to-die law with safeguards highlighted and summarized.
This right-to-die law could be a starting place
for other provinces considering creating their own health-care laws.
Other places on the Earth could also adapt these principles:
"Putting the Right-to-Die into Health-Care Laws and Regulations:
Authorized Medical Methods of Managing Dying,
Safeguards for Life-Ending Decisions":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-HCLAWS.html
A very brief explanation of each medical method of managing dying:
"Five Medical Methods of Managing Dying":
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/MMMD.html
26
recommended
safeguards for life-ending decisions.
Lawmakers
could include at least the best of these safeguards
in
any new right-to-die legislation.
Each
safeguards is explained in a page or two on the Internet.
Go to
the beginning of this website
James
Leonard Park—Free
Library