Today, 2% of the world’s population has access to assisted suicide or euthanasia, and in these jurisdictions such legislation is impacting on hospice and palliative care.
Claims that legalising assisted dying expands patient choice conflicts with increasing evidence that access to palliative care remains inequitable and inconsistent. In Canada, less than half of patients who participate in assisted suicide or euthanasia see a specialist palliative care team, and only 15% of Canadians have access to publicly funded palliative care at home.(1,2) Two thirds of all dying individuals in Belgium do not access specialist palliative care, (3) and in Australia 59% of dying intensive care patients are not referred to such end-of-life care services. (4) In addition, the evidence from official reports reveals that many assisted deaths are not in the last phase of their illness but are fearful of being a burden.
This evidence raises a serious concern that many who choose to participate in an assisted death do so, not because it is the best choice from an array of good end-of-life options, but because it is the only option.
We should also question claims that legalising assisted death is compatible with palliative care and does not impede its development.(5,6) In Canada, funding to several hospices has been withdrawn because they refused to participate in assisted deaths.(7) In Oregon in 2012, two thirds of hospice programs did not take part in assisted deaths.(8) A tension is developing between hospices providing death and those caring for the dying.
Further, up to one half of doctors who participate in an assisted death experience significant psychological and emotional distress.(9) Refusals by physicians in Canada to participate in assisted deaths are not based on religious or moral grounds, but because of the emotional burden of enacting a patient’s premature death and awareness of psychological repercussions on themselves and the clinical team.(10) A survey of healthcare professionals in Oregon, Flanders and Quebec found divisive relationships between palliative care and assisted dying.(11) This can only worsen, with 1 in 24 of all Dutch deaths being an assisted death and Canada close behind.
There is a profound impact on palliative care caused by pressure on clinicians to provide assisted deaths on demand.(12) Society may decide, through parliament, whether or not ‘assisted dying’ is legalised in the UK, but it is increasingly clear that the practice must not be part of NHS provision. Better access to palliative care and end-of-life needs to be funded as a core provision, available 24/7.(13) Heart-rending stories of bad care are not solved by diverting clinical teams away from trying to improve quality of life, towards undertaking onerous assessments of eligibility for lethal drugs.
Claud Regnard, Honorary Consultant in Palliative Care Medicine, St. Oswald’s Hospice, Newcastle-upon-Tyne, NE3 1EE
- Munro C, Romanova A, Webber C, Kekewich M, Rayelle R, Tanuseputro P. Involvement of palliative care in patients requesting medical assistance in dying. Canadian Family Physician, 2020; 66: 833-42. https://www.cfp.ca/content/66/11/833
- Access to Palliative Care in Canada. Ottowa: Canadian Institute for Health Information, 2018, p6. See: https://www.cihi.ca/sites/default/files/document/access-palliative-care-2018-en-web.pdf
- Maetens A, Beernaert K, Deliens L et al. Who finds the road to palliative home care support? A nationwide analysis on the use of supportive measures for palliative home care using linked administrative databases. PLOSOne, 2019; 14(3): e0213731. https://doi.org/10.1371/journal.pone.0213731
- Mitchell I, Lacey J, Anstey M et al. Understanding end-of-life care in Australian hospitals. Australian Health Review, 2020; https://doi.org/10.1071/AH20223
- Dierickx S, Deliens L, Cohen J, et al. Involvement of palliative care in euthanasia practice in a context of legalized euthanasia: a population-based mortality follow-back study. Palliative Medicine 2018; 32(1): 114–122.
- Chambaere K, Bernheim JL. Does legal physician-assisted dying impede development of palliative care? The Belgian and Benelux experience. Journal of Medical Ethics, 2014; 41(8): http://dx.doi.org/10.1136/medethics-2014-102116
- Harding L. Delta Hospice Society envisions new private MAID free facility. Western Standard, 18July 2021: https://westernstandardonline.com/2021/07/delta-hospice-society-envisions-new-private-maid-free-facility/
- Campbell CS, Cox JC. Hospice-assisted death? A study of Oregon Hospices on death with dignity. American Journal of Hospice and Palliative Medicine, 2012; 29(3): 227-35
- Kelly B, Handley T, Kissane D, et al. “An indelible mark” The response to participation in euthanasia and physician-assisted suicide among doctors: a review of research findings. Palliative and Supportive Care, 2019; 18(1): 82-8. https://doi.org/10.1017/S1478951519000518
- Bouthillier M-E, Opatrny L. A qualitative study of physicians’ conscientious objections to medical aid in dying. Palliative Medicine 33(9): 121-20.
- Gerson SM, Koksvik GH, Materstvedt LJ, Clark D. Assisted dying and palliative care in three jurisdictions: Flanders, Oregon and Quebec. Annals of Palliative Medicine; 2020 http://dx.doi.org/10.21037/apm-20-632
- Mathews JJ, Hausner D, Avery J et al. Impact of medical assistance in dying on palliative care: a qualitative study. Palliative Medicine 2021; 35(2): 447-54.
- Hospice care in the UK. London: Hospice UK, 2016. http://www.hospiceuk.org/docs/default-source/What-We-Offer/publications-documents-and-files/hospice-care-in-the-uk-2016.pdf?sfvrsn=0
We are grateful to Dr Claud Regnard for sharing his personal views in this editorial. ehospice welcomes open debate on all aspects of hospice, palliative and end of life care.