‘UNEASY’ FEELING ON EUTHANASIA
DOCTORS FEAR WHAT COULD GO WRONG WHEN ADMINISTERING ASSISTED SUICIDE
Canada’s anesthesiologists, doctors who work every day with some of the drugs commonly used in euthanasia and assisted suicide, are warning hastened death may not always result in a peaceful exit.
They say patients could experience convulsions, or a longer-than-expected “time to death,” or “awakenings” while the fatal cocktail of drugs take effect. Some are even questioning whether they — or any other doctor — ought to be involved at all, and recommend the task be left instead to “euthanists” or some other group.
“We suggest the burden of proof lies with the Supreme Court (of Canada) to demonstrate the legitimacy of the nomination of physicians as the exclusive purveyors of a non-medical practice,” Dr. Cheryl Mack and co-author Dr. Brendan Leier write in this month’s edition of the Canadian Journal of Anesthesia, “particularly when the ethos of medicine has historically forbidden participation in this very act.”
Justin Trudeau’s Liberals now have until June to craft federal assisted-death laws after the Supreme Court of Canada Friday agreed to extend the deadline for decriminalized assisted dying by four months. On Monday, a special joint Senate-House of Commons committee began its meetings to formulate the legislation.
In an interview, Mack said doctors are feeling pressured. “A timeline set by the Supreme Court for legislation is one thing, but for us to actually get to the point we can safely provide it is another,” said Mack, an assistant professor of anesthesiology and pediatric palliative care medicine at the University of Alberta. “It just seems like it’s coming awfully fast.”
In one of several articles on assisted death in the anesthesia journal, Mack and Leier say anesthesiologists will likely be unable to avoid the issue, given their expert knowledge of the drugs used in assisted death, and their skill in accessing veins. “We need to consider this matter carefully, use sound medical judgment and seriously think through the highly contestable nature of what the courts (and perhaps our government) are asking us to undertake,” they write.
Mack, chair of the clinical ethics committee for University of Alberta hospitals, said she and her co-author don’t object, in principle, to a “rational” suicide. “But that’s assuming, of course, we can distinguish between what is a rational suicide, and what is an irrational one.”
Anesthesiologists, she said, have several concerns: Will they be asked to develop euthanasia “recipes”? Will they have to determine the patient’s state of mind? The heart of informed consent is warning patients of the potential risks, but doctors won’t have a handle on the risk percentages “when we’re first starting out with this.”
Patients can respond to drugs differently and in unanticipated ways. Dosing is based on careful titration and monitoring of the patient, she said. “We can foresee potential complications.”
For example, with assisted suicide, where the doctor prescribes a fatal drug overdose the patient takes himself, “depending on what kind of safeguards are in place, and who’s present, you can have reactions to overdose — convulsions, vomiting, aspirations,” Mack said. “We could actually have patients incurring harm that they may not have anticipated.”
With euthanasia, or death by lethal injection, Mack raised the possibility of “awareness”— a rare but feared, and terrifying complication of general anesthesia during surgery, where the sleep drugs fail, and the patient wakes up but is paralyzed.
Euthanasia usually involves a three-step process: a drug to relax the patient, a general anesthetic such as propofol to induce an artificial coma, and, finally, a neuromuscular block that causes respiratory arrest, cardiac arrest and death.
During surgery, “We take a lot of care with our monitoring and our assessment of the patient to judge depths of anesthesia,” Mack said. But if an error is made during euthanasia — and the muscle relaxant injected before the person is in a coma deep enough to prevent feeling the effects — he or she could die by suffocation while paralyzed, but conscious.
Guidelines for doctors in Quebec, where the first deaths from euthanasia have been reported since the act became legal in that province in December, state that while the risk of loss of consciousness being “inadequate” or too brief is low, the drugs may be less effective if the IV catheter isn’t inserted properly, or the drugs injected too slowly.
“The other concern is, how do you establish a standard of care for assisted death? How do you judge competency?” Mack said. She performs hundreds of anesthesia procedures a year to maintain her competency. “What would that look like for assisted death?”
In its historic ruling striking down the Criminal Code provisions against doctorassisted death, the Supreme Court said no doctor should be compelled to participate against his or her personal beliefs.
“I think a lot of people feel uneasy with the entire concept of this,” said Dr. Susan O’Leary, president of the Canadian Anesthesiologists’ Society. “This is not what we intended when we became anesthesiologists.”