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Four issues raised by the end-of-life report

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A patient presents her doctor with a carefully crafted legal document that lays out the treatment she wants if she becomes incapable of making decisions – including stopping treatment under certain conditions or keeping her alive through artificial means.

In almost all parts of Canada, respecting advance directives for end-of-life care (and living wills) is required practice. But many Canadians don't have a will, or haven't discussed the contents with their families. A key recommendation of the report was educating Canadians to complete and discuss living wills, and for the health-care system to ensure that these documents follow the patient through the medical system.

A 65-year-old man is in a persistent vegetative state. His family believes he would have wanted to be resuscitated if he suffered a cardiac arrest. His doctors feel that this measure is futile and want to put a Do Not Resuscitate order on his chart.

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In this scenario, the report concluded, the law needs to be clarified. In some cases, courts found that doctors could withhold treatment at their discretion, but more often courts ruled that the issue is not clear. Some ethical papers have argued for doctors having the final say when they believe requests for treatment are not in the best interest of the patient. Others say that the decision rests with the family, or that conflicts should be resolved by another process, such as a tribunal. Clarifying this situation was one of the recommendations of the report.

A 55-year-old woman is admitted to hospital in severe pain with pancreatic cancer. Doctors are unable to ease her suffering. Her family asks her doctor to put her under deep and continuous sedation , as they believe she would desire if she was competent to make the decision, and refuse artificially feeding her or giving her liquid.

Sedating a palliative patient in pain is legally acceptable, the report said – although it is not clear how far the definition of pain goes. Can it be psychological? Or only physical? Withholding nutrition is also legal when a patient gives informed consent. But, again, it's not clear whether it is legal when a patient is under sedation and has not given consent. The situation becomes even more complicated for doctors if family members disagree over the course of action, and the patient's wishes are unknown.

A woman is suffering from an advanced stage of ALS that has left her irreversibly paralyzed from the neck down and unable to swallow or breathe on her own. By communicating through eye blinking, she asks her physician for a lethal injection.

This is the specific law that the report suggested needs to be changed: voluntary euthanasia or assisted suicide (for instance, a doctor prescribing barbiturates for a patent who wants to take his own life) are both illegal. The report proposes that doctors should be permitted to assist informed, competent adults, within a regulated system that would require a second opinion from another physician and a cooling-off period to determine the decision is clear and voluntary. This very case – a woman diagnosed with ALS and seeking the right to choose the manner of her death – is being argued this week before the Supreme Court of British Columbia.

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Erin Anderssen writes about mental health, social policy and family issues. More

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