‘Dad got the death he wanted’

AS­SISTED DEATH CRI­TE­RIA CHAL­LENGED

Montreal Gazette - - Canada - BRIAN HUTCHIN­SON in Van­cou­ver Na­tional Post bhutchin­son@na­tion­al­post.com

Richard Brown wanted to die. An el­derly wid­ower who lived by him­self in the same Van­cou­ver house that he had owned for decades, he wasn’t ter­mi­nally ill. He wasn’t im­mo­bile. He had coro­nary heart dis­ease and he’d en­dured painful episodes of gout. He’d been in hos­pi­tal fre­quently.

In July, around the time of his 94th birth­day, he told his el­dest son he “wasn’t plan­ning on adding an­other digit” to his age.

Jeremy Brown knew this was not a ca­sual re­mark. His fa­ther had made com­ments be­fore about “not want­ing to be around much longer.”

An en­gi­neer by pro­fes­sion, Brown was “a very in­de­pen­dent” per­son, stoic and soli­tary, says his son. With his health in de­cline and his needs in­creas­ing, he feared he was be­com­ing a bur­den. (Names have been changed at the fam­ily’s re­quest.)

“This isn’t a joke, is it?” Jeremy asked his fa­ther.

“No, it’s not,” Richard said. “I have re­sources.”

He’d set aside some seda­tives, pre­scribed to his wife be­fore her death al­most 10 years ear­lier. Jeremy in­ves­ti­gated and learned the pills would not amount to a lethal dose. “I was re­ally un­happy with his am­a­teur plan for an over­dose,” he says.

So the plan changed, to as­sisted death.

Jeremy says his fa­ther was “well-versed” in Canada’s con­tro­ver­sial new med­i­cal as­sis­tance in dy­ing (MAiD) laws, which came into ef­fect in June. The laws per­mit eu­thana­sia in cer­tain cir­cum­stances, but their word­ing can seem vague. That’s caus­ing dis­agree­ment in med­i­cal com­mu­ni­ties and un­cer­tainty among pa­tients and their fam­i­lies.

“Dad wasn’t sure if he qual­i­fied,” Jeremy re­calls. So he made in­quiries on his fa­ther’s be­half, and those led them to Ellen Wiebe.

A Van­cou­ver-based doc­tor with nearly four decades ex­pe­ri­ence in fam­ily medicine, Wiebe has lately be­come one of Canada’s lead­ing ad­vo­cates for med­i­cally as­sisted death. Since the new laws came into ef­fect, she has pro­vided dozens of peo­ple with lethal doses of seda­tives, all by in­tra­venous in­jec­tion.

Richard Brown would be her 32nd. They made an ap­point­ment: He would die in his bed, on Thanks­giv­ing Sun­day.

“There’s no way he could live (alone in his Van­cou­ver house) any longer. The only al­ter­na­tive to death is as­sisted care, and he said ‘never,’ to that,” Wiebe told the Na­tional Post, a few days be­fore the lethal in­jec­tion was to take place.

“He’s right at the end,” she added.

Not ev­ery­one seemed so sure.

Un­der the new MAiD laws, a doc­tor or nurse, with an­other health-care provider present, can ad­min­is­ter a lethal in­jec­tion or oral for­mula, but only if the pa­tient matches a num­ber of cri­te­ria.

For ex­am­ple, the per­son must be at least 18 years old and “ca­pa­ble of mak­ing de­ci­sions with re­spect to their health.” They must make the re­quest vol­un­tar­ily. They must give in­formed con­sent af­ter “hav­ing been in­formed of the means that are avail­able to re­lieve their suf­fer­ing, in­clud­ing pal­lia­tive care.”

And they must have a “grievous and irremediable med­i­cal con­di­tion” which, ac­cord­ing to the new laws, also means they must have “a se­ri­ous and in­cur­able ill­ness, dis­ease or dis­abil­ity” and be “in an ad­vanced state of ir­re­versible de­cline in ca­pa­bil­ity.”

In ad­di­tion, “their nat­u­ral death” must be “rea­son­ably fore­see­able, tak­ing into ac­count all of their med­i­cal cir­cum­stances, without a prog­no­sis nec­es­sar­ily hav­ing been made as to the spe­cific length of time they have re­main­ing.”

There are prob­lems with the new laws, says Grace Pas­tine, lit­i­ga­tion di­rec­tor at the B.C. Civil Lib­er­ties As­so­ci­a­tion. “Doc­tors are strug­gling with the term ‘rea­son­ably fore­see­able.’ ” It could mean “soon,” or it could mean some­thing else, says Pas­tine. “It’s a ma­jor flaw in the leg­is­la­tion.”

The as­so­ci­a­tion is chal­leng­ing the MAiD laws and has filed a no­tice of civil claim in B.C. Supreme Court against the At­tor­ney Gen­eral of Canada, with coplain­tiff Ju­lia Lamb, a 25-yearold wo­man from Chilli­wack who suf­fers from spinal mus­cu­lar at­ro­phy. They al­lege the new as­sisted death laws are un­con­sti­tu­tional.

Lamb was di­ag­nosed when she was six months old, and she’s been in a wheel­chair since the age of six. The dis­ease causes weak­ness and wast­ing in her vol­un­tary mus­cles. Lamb “cur­rently is not ca­pa­ble of any daily liv­ing ac­tiv­i­ties and re­quires as­sis­tance for bathing, dress­ing, toi­let­ing and pre­par­ing meals,” her law­suit reads. Her lung ca­pac­ity “is cur­rently only at 30 per cent.”

She wants to plan for the day the dis­ease brings her “to the point of en­dur­ing and intolerable suf­fer­ing.” But even then, she might not qual­ify for MAiD be­cause she could live for many more years.

She “has no way to know how and when her dis­ease will progress, but she knows that it is pos­si­ble that it will bring intolerable suf­fer­ing upon her and that the time pe­riod she will be left in that state could be of un­known and un­bear­able du­ra­tion,” the law­suit reads.

“My big­gest fear is that if my con­di­tion sud­denly gets much worse, which can hap­pen any day, I will be­come trapped,” Lamb told re­porters at a press con­fer­ence in June, af­ter her law­suit was filed.

“If my suf­fer­ing be­comes intolerable, I would like to be able to make a fi­nal choice for how much suf­fer­ing to en­dure.”

Richard Brown’s case was dif­fer­ent. He was ready to die im­me­di­ately, or as soon as his death could be ar­ranged.

Med­i­cal staff at St. Paul’s Hos­pi­tal in Van­cou­ver were wellac­quainted with him. Brown had been ad­mit­ted to their hos­pi­tal in July with a case of gout, and again in Au­gust, when he pre­sented with pneu­mo­nia and then ex­pe­ri­enced an­other heart fail­ure.

Dur­ing his week­long re­cov­ery in Au­gust, Brown told St. Paul’s staff he wanted a med­i­cally as­sisted death. That couldn’t hap­pen in their hos­pi­tal. St. Paul’s is man­aged by Prov­i­dence Health Care, a Catholic, faith-based or­ga­ni­za­tion that re­fuses to pro­vide or coun­sel eu­thana­sia.

“We have a long-stand­ing moral tra­di­tion of com­pas­sion­ate care that nei­ther pro­longs dy­ing nor has­tens death of pa­tients, plac­ing great em­pha­sis on pal­lia­tive, hospice and endof-life care,” ex­plains a Prov­i­dence pub­lic af­fairs of­fi­cial.

St. Paul’s staff held a “fam­ily meet­ing” with Brown and his son Jeremy. Ac­cord­ing to a dic­tated note from a St. Paul’s pal­lia­tive care doc­tor, Brown in­di­cated at the meet­ing “that he wished to pur­sue med­i­cal as­sis­tance in dy­ing in the com­mu­nity … (but) based on the cur­rent cri­te­ria, Mr. (Brown) does not qual­ify as he, in our opin­ion, does not have an ill­ness that will cause death in the fore­see­able fu­ture.”

“At the time of dis­charge,” the note con­tin­ues, “Mr. (Brown) was, in our team’s opin­ion, able to man­age at home alone.”

The note was sent to Wiebe af­ter Brown had left St. Paul’s for the last time.

Wiebe didn’t share the St. Paul’s opin­ion; she had vis­ited with Brown be­fore his dis­charge. The visit was some­what dis­guised. Wiebe doesn’t have doc­tor’s priv­i­leges at St. Paul’s, so she some­times ar­rives at that hos­pi­tal bear­ing flow­ers, look­ing as if she’s a rel­a­tive or friend to a pa­tient.

She won’t ac­knowl­edge that she “as­sessed” or con­sulted when she saw Brown at St. Paul’s.

“Peo­ple have ac­cused me of prac­tis­ing medicine without hos­pi­tal priv­i­leges,” she says. “I can get into trou­ble for that.” But she did man­age to ex­am­ine Brown’s records, and she spoke with him for about half an hour. She con­cluded he qual­i­fied for a med­i­cally as­sisted death.

Jeremy was there for the en­counter. “Dad said, ‘I can’t take it any more,’ and started weep­ing. Dr. Wiebe had punc­tured his ar­mour. For the first time, I saw the emo­tional weight be­hind his de­ci­sion.”

Wiebe wrote back to St. Paul’s, not­ing that Brown “is 94 and has just been hos­pi­tal­ized with pneu­mo­nia and heart fail­ure AND he re­fuses any fur­ther life-pro­long­ing treat­ment, in­clud­ing an­tibi­otics … I would be very sur­prised if he lived as long as one year without any life-pro­long­ing treat­ments.”

Fur­ther­more, Wiebe wrote, “the law is clear that it is the pa­tient’s own assess­ment that their life is intolerable due to their grievous and irremediable con­di­tion that mat­ters. He has the right to MAiD and I will hon­our his wishes.”

Brown was by then back at his house, pre­par­ing for his fi­nal days: He wrote some farewell cards to old friends, to be mailed af­ter his death. He made a con­tri­bu­tion to the St. Paul’s Foun­da­tion, a char­ity man­aged by the hos­pi­tal.

He wanted no obit­u­ary, no fu­neral. He wished to go qui­etly and “without any fuss,” his son told the Post, three days be­fore Brown was to die.

But things were “a bit com­pli­cated,” Jeremy ac­knowl­edged. His fa­ther had asked that no one else know about his plan, not even his other chil­dren. “Dad wants it to be a sur­prise,” Jeremy said.

Think­ing it would be un­fair to hide his fa­ther’s ar­range­ments, Jeremy de­cided to in­form his two broth­ers without dis­clos­ing the date.

“I just said (his death) would come soon,” Jeremy says. “My broth­ers are not at all happy about it. They were shocked and an­gry when I told them. One said he wanted no part of it. They said if it wasn’t for me, this wouldn’t be hap­pen­ing, that it’s very ac­cel­er­ated. It might have been bet­ter if we had cov­ered it up.”

Fol­low­ing his fa­ther’s wishes, Jeremy agreed he would not be at the house when the doc­tor ar­rived, nor would he wit­ness the in­jec­tion.

The old­est per­son for whom Wiebe has pro­vided as­sisted death was 102. The youngest was 42. She has had to de­cline some re­quests. “I have to say no when a grievous con­di­tion will not shorten a life,” Wiebe says.

She sources the drugs, a com­bi­na­tion of mus­cle re­lax­ants and the seda­tives mi­da­zo­lam, propo­fol and rocuro­nium. Wiebe says she’d pre­fer to use bar­bi­tu­rates, which work more quickly, but those aren’t al­lowed in Canada. That too must change, says Wiebe.

Her pa­tients de­cide where they will die. Some­times, it’s at their home. Some­times, it’s at her clinic, or in­side a hos­pi­tal that al­lows MAiD.

Fam­ily mem­bers are usu­ally present. Pets can be in­cluded.

“My last one, he’d had three can­cers, heart and lung dis­ease. His wife climbed into bed with him,” Wiebe says with a smile. “He was 72. He was count­ing down the hours. He called me his an­gel.”

She dis­cusses with the pa­tient for the last time their wish to die. Once con­firmed, she ad­min­is­ters a mus­cle re­lax­ant. Then, she in­jects the lethal dose of seda­tives; it usu­ally takes the pa­tient about 10 min­utes to die.

The fu­neral home is then called, and some­one comes to pick up the body. Wiebe signs off on the death cer­tifi­cate. The mood can be solemn or happy, even “up­lift­ing,” says Wiebe. It all de­pends on who is around. If friends and fam­ily are griev­ing, the emo­tional im­pact can take a toll.

Wiebe and her nurse ar­rived at the Brown house on Thanks­giv­ing Sun­day, be­fore noon. As he had re­quested, none of Brown’s chil­dren were there; he’d spent time with his sons the day prior. A fam­ily friend let the doc­tor and nurse in­side.

“I ac­cepted the of­fer of a cup of tea while I pre­pared my sy­ringes,” Wiebe said later. Brown was in bed. He looked out­side the win­dow. “It’s a golden day,” he re­marked. He turned to Wiebe and apol­o­gized for “in­ter­fer­ing” with her Thanks­giv­ing.

She ad­min­is­tered the drugs and he died.

Jeremy re­ceived a phone call and went to the house. When he saw his fa­ther, no longer liv­ing, emo­tions over­came him. “I lost it,” he said later.

His broth­ers knew their fa­ther’s death was com­ing, but they seemed sur­prised when re­ceiv­ing the news, says Jeremy. They didn’t fly off the han­dle, much to his re­lief, and “things have set­tled down. … Since then, I’ve been filled with a joy­ous sat­is­fac­tion. Dad got the death he wanted.”

The type of death, he be­lieves, that his fa­ther de­served.

THE LAW IS CLEAR THAT IT IS THE PA­TIENT’S OWN ASSESS­MENT THAT THEIR LIFE IS INTOLERABLE DUE TO THEIR GRIEVOUS AND IRREMEDIABLE CON­DI­TION THAT MAT­TERS. HE HAS THE RIGHT TO MED­I­CAL AS­SIS­TANCE IN DY­ING. — DR. ELLEN WIEBE

DARRYL DYCK / THE CANA­DIAN PRESS

Since the new as­sisted dy­ing laws have come into ef­fect in Canada, Dr. Ellen Wiebe has pro­vided dozens of peo­ple with lethal doses of seda­tives, all by in­tra­venous in­jec­tion.

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