When Larry Librach began practising medicine in 1970, few people would have understood the term palliative care. And if they understood it, they might have found the idea shocking. Alleviating symptoms with the use of opiates instead of treating their cause was seen as dangerous, something that could lead to addiction.
That assisting terminally ill patients to achieve a good death in an environment of their choosing has since gained acceptance in Canada is thanks in part to the efforts of Dr. Librach. He became one of the foremost experts on palliative care in the world, co-founding the Temmy Latner Centre for Palliative Care at Mount Sinai Hospital in Toronto, which he ran for 22 years. As a teacher, he helped develop the field into a specialty with uniform standards and practices taught at medical schools in this country and abroad. Today, the membership of the Canadian Society of Palliative Care Physicians, formed 20 years ago, numbers more than 300 specialists.
After he retired from Mount Sinai, Dr. Librach continued to engage with end-of-life issues as director of the Joint Centre for Bioethics at the University of Toronto, which provides post-graduate education to ethicists.
But an equally remarkable achievement was the manner of his own end, on Aug. 15 from advanced pancreatic cancer, which he used as his final teaching opportunity.
His colleague Jennifer Gibson, interim director of the Joint Centre for Bioethics, recalls that Dr. Librach returned from a Florida vacation last spring with gastrointestinal issues. "Our leadership team knew that he was getting tested," Dr. Gibson said. "On April 8, he came into our meeting and said, 'I need to tell you I am dying, and this is my last day.' He wasn't going to sugarcoat it. We all had a good cry."
Dr. Librach left his office for the last time at noon that day but kept his colleagues up to date by e-mail, not only about his condition but his changing emotions. "He discussed his experience going into chemo and he told us he was scared," Dr. Gibson recalled. "He was seeing things as a patient that he did not see as a health-care provider. He was a carer and a teacher till the end."
Dr. Librach recorded a video, posted on YouTube, in which he discussed the importance of not losing hope. "If your hope is to live forever, forget it," he baldly stated. Hope changes. His was to be able to die at home, he said in the video. He also started drafting a book with writer Phil Dwyer to be titled Dying in the First Person, and became the subject of a documentary for the CTV program W5.
"At first he did not want chemotherapy. Larry knew too much," said his wife Faye Librach. "Then his oncologist persuaded him to try a new type of chemo, and he managed six treatments over a couple of months. Then he started to get severe side effects." After hospital admissions and a CT scan that showed the cancer had spread even more, he asked to go home. His former medical colleagues at the Temmy Latner Centre were now charged with relieving the pain their former boss was experiencing.
"People always think this is a depressing field," said Ms. Librach, a retired school principal, "but those who work in this field don't think that. Larry did not think so. He died the way he wanted others to. He was not in pain. He was not hooked up to machines. He died peacefully. We were not put in the situation of having to make decisions about pulling the plug."
Lawrence Librach was born in Toronto on June 5, 1946, one of two children of Joe and Sue Librach. His father, a tailor, had emigrated from Poland as a youth between the wars, and later learned that his family there had been killed in the Holocaust.
From earliest childhood, Larry wanted to be a doctor. He was an honour student all through William Lyon Mackenzie secondary school in the city's north end. In his senior year, he met Faye Roth on a blind date. There was no initial spark, but later at the University of Toronto, when he was in his second year of pre-med and she was studying to be a teacher, the two connected again and found much in common. Their marriage resulted in two children, David and Judith.
Dr. Librach started a private practice in the city's Kingsway area before joining Toronto Western Hospital, where he became chief of family medicine in the 1970s. He was also by then on the medical faculty at U of T, eventually becoming a full professor.
At Western hospital, Dr. Librach was trying unsuccessfully to help a patient who was suffering greatly from cancer. Then he had the opportunity to attend a conference in Montreal where Balfour Mount was speaking. Dr. Mount, who first coined the term "palliative care," had been influenced by his reading of Swiss-born psychiatrist Elisabeth Kubler-Ross and had started a palliative ward for the dying within Montreal's Royal Victoria Hospital in 1975.
After learning of Dr. Mount's methods of pain control, Dr. Librach was able to help his cancer patient at Western die peacefully. He turned to the study of pain control, spending a sabbatical year in Edinburgh, working with another palliative-care pioneer, Derek Doyle. Dr. Doyle, a former Christian missionary to South Africa, had founded St. Columba's Hospice in 1977, where he developed not only more effective clinical techniques, but educational and research approaches that paved the way for a new specialty that could be integrated into mainstream medicine.
Having become more proficient in pain control, Dr. Librach worked at Mount Sinai in Toronto with Dr. Frank Ferris (who now practises in Ohio). The two doctors took turns being on call daily and on weekends to visit the dying at home to provide pain relief. In the 1980s, they not only looked after incurable cancer patients, but were the first in the city to provide palliative care to those dying of AIDS. Counselling patients and families was another important aspect of their work, along with teaching other doctors.
"Larry was, above all, an honest and compassionate man who believed that all Canadians should have access to top-notch palliative care," writer Phil Dwyer said in an e-mail. "Despite his eminence and celebrity in the palliative-care community, he was always approachable and ready to help anyone at almost any time."
In addition to teaching pain relief at U of T's medical school, Dr. Librach published The Pain Manual, a small pocket book for palliative doctors, and co-edited a textbook, Palliative Care: Core Skills and Clinical Competencies.
"The Pain Manual is a fantastic resource," says Russell Goldman, director of the Temmy Latner Centre.
"It tells you how to start morphine, how to adjust the dose. How to deal with the side effects like constipation and nausea. How to use Percocet. People tend to be undertreated for cancer pain because doctors are afraid to order it, afraid of the repercussions."
Pain, however, does not always disappear. In about 5 per cent of cases, palliation is "exceptionally challenging," according to Dr. Goldman: "The goal is to get it to the point where it is tolerable."
While Dr. Librach rejected physician-assisted suicide, he tempered his views in his later years in cases where palliation was ineffective.
His impact was international. He consulted at Northwestern University in Chicago and was consulting on palliative care education in Trinidad not long before his death. He took groups of palliative care doctors to China and Russia on exchange programs, Ms. Librach said.
At a conference on gerontology in Brazil, a Roman Catholic priest named Leo Pessini, whose San Camillo order runs a hospital, approached Dr. Librach after being impressed by his talk. He wanted to explore Dr. Librach's ideas further because his hospital in Sao Paulo, Instituto Brasileiro de Controle do Cancer, was not consistent in its care of the dying. Two years ago, on the Canadian doctor's next visit, the priest surprised him by formally opening the Lawrence Librach wing of his hospital, with eight palliative beds.
On the subject of his own death, Dr. Librach was remarkably honest and unsentimental.
"On the days when he was down, or afraid, he would talk very openly about it," recalled Mr. Dwyer. "For the most part, however, he died as he had lived: with intention and passion."
Dr. Librach leaves his wife Faye, children Judith and David, sister Barbara, three grandchildren and many colleagues and former students he has influenced.