2023-07-31 05:05:59
The general public knew the Dre Diane Francœur as President of the Federation of Medical Specialists of Quebec. This time, it is to raise awareness of another way to die with dignity – with continuous palliative sedation – that Dr.re Francœur made a point of expressing herself here, about the death of her spouse, Dr.r Francis Engel.
Since the entry into force of medical assistance in dying in Quebec in December 2015, requests have continued to grow. So much so that in just a few years, it has become more common here than in Belgium or the Netherlands, where it has been used for decades. In 2021-2022, medical assistance in dying was chosen by 3,663 Quebecers, representing 5.1% of deaths*.
For the family of Dr Engel, this avenue was not considered. The Dr Francis Engel, just like the Dre Francœur and their children, felt that deciding well in advance that it would happen “Monday, at 9 a.m.”, and that the curtain would fall very quickly, was too brutal.
The chemotherapy had been stopped, she couldn’t do anything for the D.r Engel, who was stricken with dazzling cancer. The end was imminent.
This idea of continuous palliative sedation, the Dre Francoeur hadn’t had it in mind at all.
“I am an obstetrician-gynecologist, I am on the side of life,” she notes.
Used when the disease is terminal and the suffering cannot be relieved otherwise, continuous palliative sedation consists in giving drugs to relieve the symptoms by lowering the level of consciousness, on a continuous basis, until death.
The patient is then plunged into a deep coma, without his death being immediate as for medical assistance in dying.
Continuous palliative sedation can last several days.
In 2021-2022, 1838 people (2.6% of deaths) obtained it. They are less numerous than those who have had recourse to medical assistance in dying.
Palliative sedation ‘doesn’t take the pain away’, but Dre Diane Francœur explains that for her family, it seemed to her “softer”.
Because it has only recently been authorized, medical assistance in dying has received a great deal of attention. Palliative sedation, hardly any, and that’s why the Dre Francoeur wanted to talk about his experience.
Palliative sedation was especially in the news when the family of Robert Bourassa denounced the fact that Andrée Simard, widow of the former Prime Minister, could not receive it at St. Mary’s Hospital, in Montreal.
The family did well to denounce him, says the Dre Francoeur. But it would be a shame, she believes, if the population concluded that this is not accessible or possible.
Specific criteria
President of the Quebec Society of Palliative Care Physicians, Dr.re Olivia Nguyen explains that medical assistance in dying, a “planned death, with a date on the calendar”, is not suitable for everyone, indeed.
Palliative sedation should not, however, be seen as an alternative to medical assistance in dying. Unlike medical assistance in dying, specifies the Dre Nguyen, death must be very imminent and the doctors must be unable to relieve the patient’s suffering otherwise. It is therefore not offered immediately or to all patients.
In the majority of cases, with modern medicine, “we do not die in uncontrolled suffering”, reminds Dr.re Nguyen. Most deaths are ‘ordinary’, in the sense that the patient is quite relieved.
When the criteria are met and the decision is made, the patient under palliative sedation will be plunged into a coma, which can last from a few days to two weeks – which is extremely rare, notes the Dre Nguyen.
D’s spousere Francoeur breathed his last in 36 hours.
When death arrives after a few days, aren’t relatives likely to become exhausted by remaining at the patient’s bedside full time, so as not to miss his last moments?
The Dre Francœur replies that the doctors who accompany people at the end of life recognize the signs of the last hours and can warn the family that death is coming very soon.
The Dre Nguyen observes that loved ones often put too much pressure on themselves to be present at the end. Beyond these very last moments, there is the love that has been given throughout life, she recalls. A person receiving continuous palliative sedation is plunged into a deep, deep sleep.
Beliefs that color decisions
Physician at the MUHC, the Dre Stéfanie Gingras explains that in the vast majority of cases, patients only need to be relieved by conventional drugs that treat pain.
But palliative sedation can be an avenue when a person is experiencing physical or existential suffering that no medicine can relieve and they say they are unable, for example, to continue like this.
It can therefore be offered to a person who has an enormous fear of dying?
In fact, answers the Dre Gingras, “in Quebec, the quality of care varies” and “depending on the expertise and knowledge of the doctor”, the practice can vary.
“The ideal remains to be able” to offer comfort to the patient, “that the suffering can be relieved otherwise”, which is normally the case.
But when the other options have not worked, we can come to this choice, especially since some patients “prefer not to be aware of anything”.
Others, on the contrary, will refuse this treatment, incapable of “cutting themselves off from everything, of agreeing to be washed when they are unconscious”, for example.
In her practice, the Dre Gingras explains that she has always seen patients die within five days of continuous palliative sedation.
Finally, she emphasizes that like medical assistance in dying, continuous palliative sedation is regulated by law. It requires consent, which can be given by a relative if the patient is no longer able to give consent himself.
What if loved ones disagree? The best thing is for a person to have a medical proxy, but the Dre Gingras says he has never witnessed dissension, as continuous palliative sedation imposes itself when it is proposed.
*The data for medical aid in dying and continuous palliative sedation come from the 2021-2022 activity report of the Commission on end-of-life care.
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