End-of-life care: the Canadian context

1. End-of-life care:the Canadian context Rels 300 / Nurs330 31 October 2013 http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

2. Of Life and Death • February 1994, Senate of Canada • Special Senate Committee established • “appointed to examine and report upon the legal, social and ethical issues relating to euthanasia and assisted suicide” • Final Report issued June 1995 • Complete text of report found online at http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/euth-e/rep-e/lad-tc-e.htm http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

3. Initial Findings • No assessment of euthanasia and assisted suicide could be done without a much broader examination of end-of-life services, treatments, and decisions • Widened scope of committee’s work • Palliative care • Pain control and sedation • Withholding and withdrawal of life-sustaining treatment • Advance directives http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

4. Further considerations & contexts • Criminal law = federal jurisdiction • Health care = provincial jurisdiction • Canadian Charter of Rights and Freedomsthe standard for both • Technological advances in medicine – especially with regard to “artificially” sustaining life processes • “institutionalization of death” – aggressive treatment; life-support • Emergence of HIV/AIDS – self-determination in dying http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

5. 1st step = terminology Clarify terminology to minimize confusion and distinguish among treatment decisions Competent =capable of understanding the nature and consequences of the decision to be made and capable of communicating this decision Incompetent =not capable of understanding the nature and consequences of the decision to be made and/or not capable of communicating this decision http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

6. Involuntary = done against the wishesof a competent individual or a valid advance directive. Non-voluntary =done without the knowledge of the wishesof a competent individual or of an incompetent individual. Voluntary = done in accordancewith the wishesof a competent individual or a valid advance directive http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

7. Palliative care =care aimed at alleviating suffering– physical, emotional, psychosocial, or spiritual – rather than curing; comfort care. Total sedation =rendering a person totally unconscious through the administration of drugs without potentially shortening life. Treatment aimed at the alleviation of suffering that may shorten life =the administration of sufficient amounts of drugs to control suffering even though this may shorten life. http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

8. Withholding of life-sustaining treatment = not starting treatmentthat has the potential to sustain the life of a patient. Withdrawal of life-sustaining treatment = stopping treatmentthat has the potential to sustain the life of a patient. Assisted suicide = intentionally killing oneselfwith the assistance of anotherwho provides the knowledge, means, or both. Euthanasia = a deliberate act undertaken by one person with the intention of ending the life of another person to relieve that person’s suffering where that act is the cause of death. http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

9. Surrogate [or substitute] decision-maker = someone who is authorized by law or by a person to make treatment decisions on behalf of an incapable person. Substituted judgment = a judgment made by a surrogate decision maker that reflects the wishes of the incompetent individualif he or she were competent. Best interests judgment = a judgment made by a surrogate decision maker on the basis of what he or she considers to be in the best interests of the incompetent individual. http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

10. Advance directive = a document executed by a competent individual concerning health care decisions to be made in the event that the individual becomes incompetentto make such decisions. Futile treatment = treatment that in the opinion of the health care team will be completely ineffective. Free and informed consent = voluntary agreement by a competent person regarding treatment options … knowledge [of] consequences … and … possible alternatives … free from coercion, duress and mistake. http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm

11. Competent Incompetent Involuntary Non-voluntary Voluntary Palliative care Total sedation Treatment aimed at alleviation of suffering that may shorten life Advance directive http://www.parl.gc.ca/35/1/parlbus/commbus/senate/com-e/rep-e/lad-tc-e.htm Withholding of life-sustaining treatment Withdrawal of life-sustaining treatment Assisted suicide Euthanasia Surrogate decision maker Substituted judgment Best interests judgment Futile treatment Free and informed consent