Thursday, October 30, 2014

End-of-life dialogue urged

TORONTO—Canada needs to create a national palliative-care strategy that will give all Canadians facing the end of life the opportunity to have “the best death possible,” says the country’s largest doctors organization.
In a report released Tuesday in Ottawa, the Canadian Medical Association also said the public, politicians, and policy-makers need to engage in a national dialogue about end-of-life issues, including discussions about such controversial topics as euthanasia and physician-assisted death.

The authors also strongly encourage individuals to talk to loved ones about their wishes regarding death, including a written advance care directive that clearly spells out how they want to spend their final days.
The report, entitled “End-of-Life Care: A National Dialogue,” follows a series of public meetings hosted by the CMA over the last year in five cities across the country, as well as online discussions.
“What the report says is Canadians want good access to palliative care,” said Dr. Louis Hugo Francescutti, president of the 78,000-member organization.
“Patients are telling us they don’t want to die in pain. They don’t want to die alone,” he added.
“And they don’t want to be a burden to their families, their friends, their caregivers.”
Palliative care is “adding quality of life to the remaining days of an individual,” Francescutti told an Ottawa news conference.
“And unfortunately, maybe 15-30 percent of Canadians—depending on your postal code—will be afforded the opportunity to have good palliative care,” he noted.
What a person wants their end of life to look like needs be discussed with family—and family members need to be open to those conversations, said the report, which suggests everyone should have advance care planning and/or directives in place.
But only about 10-15 percent of Canadians have undertaken that kind of planning with their families, Francescutti said.
“Once Canadians understand that it’s important that they share their wishes as to end-of-life issues with their family members, then we need to make sure these are respected, no matter where the jurisdiction is,” he stressed.
In some cases, he noted, the health-care institutions didn’t live up to the wishes expressed by the dying patient and their loved ones.
“Canadians should periodically revisit these issues as things change, and make it crystal clear that it’s not just old people that die; we can all, at a moment’s notice with a diagnosis, be put in a situation where end of life becomes an issue for our children or ourselves,” Francescutti warned.
Dr. James Downar, a palliative-care specialist at Toronto General Hospital, lauded the CMA’s call for a national strategy to provide specialized compassionate care for the dying.
“And we need to get behind that, and give it some teeth and give it some funding,” he remarked, noting about 95 percent of the 240,000 Canadians who will die this year will have non-sudden deaths—often resulting from a chronic illness—and could be referred for palliative care.
Downar also was pleased to see attention given to advance care planning, and the report’s detailing of the challenges that can be involved.
“Everyone does support the idea of talking about death and dying and values, but it’s not always as straightforward as many people believe,” he said.
“So highlighting some of those challenges makes it a bit more real for people reading the report.
“They may get a better idea about the kinds of questions they should be asking and the kinds of conversations they should be having,” he added.
For instance, a person may say they want to be “kept comfortable at home” as their life comes to a close.
But some pain relief cannot be provided in the home, so planning must include whether the patient is willing to go to hospital for advanced care, Downar explained.
Or if home care becomes too much of a burden for the family, would the dying patient be amenable to going to hospital or a palliative-care placement?
“Even what may seem like a very clear instruction to most of us doesn’t necessarily translate into a plan that can be easily implemented,” Downar stressed.
The CMA report also discusses euthanasia and physician-assisted death, and Francescutti said there still is much divisiveness over the issue of helping someone to end their life—both among the public and doctors.
But even those who support the legalization of medically-enabled death said they would want to see many restrictions, including protection for the elderly or those with severe physical or mental disabilities from being euthanized against their will.
Doctors also want to avoid such a slippery slope, Francescutti said.
“We would absolutely, as a profession, make sure that vulnerable individuals and vulnerable populations are protected.”

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