Summer (Volume 28, Number 2)
MAiD in Rheumatology
By Philip A. Baer, MDCM, FRCPC, FACR
“Without health life is not life; it is only a state of
langour and suffering – an image of death" – Buddha
“People fear death even more than pain. It's strange
that they fear death. Life hurts a lot more than death.
At the point of death, the pain is over. Yeah, I guess it is
a friend.”
– Jim Morrison
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As I alluded to in our last issue, the applicability of
medical assistance in dying (MAiD) to rheumatology
may come as a surprise to many of our colleagues.
While I followed the debate on euthanasia and assisted dying
from the Sue Rodriguez case in the 1990s through the
dying pleas of Dr. Donald Low and his wife Maureen Taylor
more recently in 2013, I never really associated our specialty
with this issue. My wife, who practiced palliative care
medicine for decades, was far more likely to be involved, I
thought. Certainly, no one was going to approach rheumatologists
to actually provide MAiD services.
With the passage of Bill C-14 in June 2016 after the Supreme
Court ruling in the Carter case, MAiD is a reality in
Canada, now accounting for about 0.9% of all deaths, and
over 2,000 deaths in total in the first year after legalization.1
Cancer, neuro-degenerative disorders and circulatory or
respiratory failure drive most requests. Controversies persist
regarding MAiD for mature minors, those with psychiatric
illnesses, and those who want to provide an advance
directive fearing dementia or other incapacity.
The current law requires that adult patients must meet
four criteria:
- Having a serious and incurable illness or disability;
- Being in an advanced state of irreversible decline;
- Enduring intolerable pain; and
- Facing a “reasonably foreseeable” death.
In 2017, an Ontario patient known as A.B. suffering from
severe osteoarthritis with chronic pain applied for MAiD.
She was initially turned down, as her physician did not
feel that her death was reasonably foreseeable, as required
by the law. She applied for judicial review, and Superior
Court Justice Paul Perell ruled that a person does not need
to have a terminal condition or be likely to die within a
specific time frame to access medical assistance in dying.
A.B.’s wishes were granted and implemented, with her death
widely publicized, at least in Ontario, when it occurred in
August 2017.
The latest development was reported on April 1, 2018, in
The Globe and Mail.2 In another somewhat controversial
scenario, an elderly couple opted for a joint MAiD procedure,
carried out in Toronto in the presence of two attending
physicians and their families. This was only the second
joint MAiD performed in Canada. Another couple had undergone
the procedure four days apart on the advice of the
CMPA, who were worried about the appearance of coercion
of one spouse by the other in the case of a simultaneous
MAiD procedure.
In this case, George and Shirley Brickenden were both
well into their 90s and living together in a Toronto retirement
home. According to the Globe, Mrs. Brickenden’s body
was “wracked by rheumatoid arthritis, an inflammatory condition
that turned her hands into swollen purple claws.”
Combined with heart failure, the requisite two independent
physicians concluded she was eligible for MAiD. However,
she had to wait for her husband to deteriorate sufficiently,
as only one of two physicians initially felt that his age and
frailty alone qualified him for MAiD. After she broke her hip
and he developed syncopal episodes, other heart issues and
recurrent infections, they both were assessed as qualifying.
Kelly Grant, the Globe reporter interviewing them and their
family days before their planned deaths still found them
“sharp, vibrant, and elegant …they seemed so happy…” and
was perplexed by their plan to die now. However, Mrs. Brickenden
called the reporter later to indicate she could not
sleep “through rheumatoid arthritis pain that was like some
sort of awful animal gnawing at her joints.”
Within one year, two highly publicized cases of MAiD
have focused on arthritic conditions. While pain is the cardinal
symptom of arthritis, the portrayal of OA and RA as
conditions warranting assisted dying may come as a surprise
to most practicing rheumatologists. While more progress
has been made in changing the natural history of RA
than OA, I am sure most clinicians feel that we can deliver
a management plan that can favourably impact pain, other
symptoms, function and quality of life in both conditions
for most of our patients. Yet we know that patient and physician
thinking regarding RA may be discordant, as was
highlighted by a recent Arthritis Society survey.3 The lesson of these MAiD cases is not that rheumatologists will necessarily be much more involved in future MAiD cases, but that we may have to do better at examining the suffering wrought by rheumatic diseases from the perspective of our patients.4,5
References:
1. Health Canada. 2nd Interim Report on Medical Assistance in Dying in Canada. Available at www.canada.ca/content/dam/hc-sc/documents/services/publications/health-system-services/medical-assistance-dying-interim-report-sep-2017/medical-assistance-dying-interim-report-sep-2017-eng.pdf. Accessed June 2018.
2. Grant, K. Medically assisted death allows couple married almost 73 years to die together. The Globe and Mail. April 2018. Available at www.theglobeandmail.com/canada/article-medically-assisted-death-allows-couple-married-almost-73-years-to-die/. Accessed June 2018.
3. The Gap Between Arthritis Health Care Providers and Patients. May 2017. Available at www.arthritis.ca/getmedia/3f0a980c-6450-44c3-bd30-e402cd678b33/Arthritis-Gap-Report-FINAL-EN-Screen.pdf. Accessed June 2018.
4. RA Matters. Available at ramatters.ca. Accessed June 2018.
5. CRA ASM 2017 Poster 3: The Objective Gap: A Survey of Patient and Health Care Professionals’ Priorities for Inflammatory Arthritis Treatment. Ed Ziesmann (The Arthritis Society [Ontario Division], Toronto); Ahmad Zbib (The Arthritis Society, Toronto); Douglas Emerson (The Arthritis Society, Toronto). The Journal of Rheumatology June 2017, 44 (6) 861; DOI: https://doi.org/10.3899/jrheum.170256
Philip A. Baer, MDCM, FRCPC, FACR
Editor-in-chief, CRAJ
Scarborough, Ontario
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