Introduction and Cases Analysis
Typically as the population ages and people are forced to incur increasing costs of health services, opting for end-of-life and planning has become a trending and significant aspect of Canadian patients, relatives and the collective Canadian system. Statistics show that most of the deaths in Canada mainly occur in hospitals, and out of this set, the most significant sub-set came from patients put under intensive care unit hospitalization and monitoring. Ironically, many Canadian elderly citizens seem to vouch for treatment plans that are less aggressive and whose main aim is to facilitate the provision of comfort to the patients rather than monopolizing efforts towards technologically-backed institutionalized death.
As part of Canada’s end-of-life law and policy, the first three aspects will deeply include; withholding and possible withdrawal of potentially life-sustaining treatment. The stated aspects are biasedly preferred given their suitability in addressing some of the conundrums that crop from misinterpretation or mal-interpretation of the Canadian law policies of end of life-care (Fowler, Robert and Michael 2013, 127-132). The demystification and analysis of the stated aspects enable us to gain an empirical comprehension and logical framework adhered to by the Canadian court system, as seen in Irving Michelle Vs Darwin Johnson and Bury Stevens vs Allison Chaplin. Consequently, the relational ties between the empirical legal aspects and disparate precedent court rulings enable scholars to gain the know-how principles utilized by courts in ruling for or against end-of-life court trials.
On the withholding and withdrawal of potentially life-sustaining treatment, a patient is provided by law the right to refuse treatment even if the refuse treatment bears the potential and capability to sustain life. The Canadian Supreme Court wrote that patients have in their capacity the right to refuse treatment, even life-sustaining treatment. The court baffled Canada by stating that they “have a right to choose how (their) body will be dealt with.” Also, a doctor “has no choice but to accept a patient’s instructions to discontinue treatment.”
To understand the critical aspects, the definition that a patient harbours the right to refuse possible curing of life-sustenance treatment has to be met by the patient meeting the criteria that; a patient is an adult, in some territories and provinces, or a mature minor. Secondly, a patient has to be competent and should never be put under pressure while deciding which side to opt for. In other words, all other parties opt to stay on the sidelines when the patient is contemplating utilizing end-of-life care in Canada.
Still, on the Canadian policies, it is imperative and mandatorily essential to have within our logical grasp whether doctors are authorized to withhold or carry out the withdrawal of this treatment without any prior form of consent. However, the law does not seem to have a solid standpoint on whether doctors are allowed to withdraw or withhold treatment without the patient’s consent. The parallel polarity with some courts ruling in favour of authorizing doctors, while others condemning such an act, there arises incongruous conundrums that opt to be addressed to shed light, or at least track a common trait in all these precedent court rulings and Canadian policies.
Given the nature of the chosen cases, we must look at the other aspect of end-of-life law in policy in Canada, which is palliative interventions. Palliative care is one of the approaches that aim to improve the patient’s quality of life and the close kin and other relatives faced with the problems that emanate from the life-threatening illness. Much focus is given to pain control and the mitigation of other severe symptoms. Additionally, chronic diseases lead to social, emotional and spiritual constraints.
Some of the palliative care practices that are utilized to induce relief from suffering and pain include the administration of drugs for pain, the use of oxygen, a patient being fed through an IV tube or nasogastric tube, the transfusion of blood products and administration of drugs to reduce nausea and the use of drugs to repress anxiety. Another disparate form of palliative care includes spiritual and counselling support.
As much as the primary intent of palliative care was to enable the patient’s comfort, there was the hefty utilization of two effective practices that seemed to hasten death. The two methods are potentially life-threatening opioid use and palliative sedation.
The understanding of potentially life-threatening opioids is a method employed by doctors commonly intended to treat pain close to the end of the cycle through that ministration of opioids. Opioids exist as drugs used to treat and relieve severe pain, such as codeine, oxycodone and Morphine. The exciting thing with opioids is that they can block pain and induce sleep; also, they’re able to cause muscle relaxation and enable slowed-down breathing. In occasionally peculiar circumstances, the drug amount needed or the rate at which the drug needs to be administered to control pain may cause severe slowing breathing that induces and fastens death. In minimal cases, will a doctor be able to tell the amount of drug given with the rate at which it might be administered without speeding up death?
It is legal to potentially use life-shortening opioids in Canada since the courts have approved that a doctor may be able to administer patients’ opioids to help relieve pain and other different forms of suffering despite the fact and the knowledge that it may cause hesitant death.
Additionally, the Supreme Court of Canada simulated that the Sue Rodriguez case in 1993 legalized the use of palliative treatments that could shorten life. The logical reasoning behind the decision was that if a doctor administered drugs to ease the pain, the possibility of causing death was different from a doctor administering the medications to pull death closer. The court stated the difference was mainly in the doctor’s intention and that the difference was clarified on a legal basis.
Palliative sedation is distinctively defined in two disparate ways. One end of the definition is the administration of drugs that lead to the loss of consciousness. At the same time, the other is the administration of drugs that cause the loss of consciousness and the stopping of any IV fluids and additional artificial nutrition. Doctors commonly employ this method when they request the next of kin or family members for palliative sedation if there is no other possibly employable way to relieve pain and suffering.
The legality of palliative sedation is a matter of concern; however, clarification kicks in since it is legal if a doctor administers continuous and deep sedation while simultaneously continuing IV fluids and artificial nutrition. However, if a doctor administers deep and continuous forms of sedation while stopping IV fluids and artificial nutrition, it may be termed or rendered illegal. The dependent factor on the former is how far the patient is from death.
Continuous and deep sedation without IV fluids and artificial nutrition is deemed legal if a patient is near death. In “very close to death” scenario indicates the expectation of death within a couple of days. The withdrawal and withholding of IV fluids and artificial nutrition do not whatsoever lead to the cause of the patient’s death.
Continuous and deep sedation without the use of IV fluids and artificial nutrition is probably legal if the patient is close to death. “a close to death” scenario indicates an expectation of death within a couple of weeks, and any form of withdrawal or withholding of the artificial nutrition or IV fluids do not lead to the cause of the patient’s death in any way.
Lastly, continuous deep sedation without artificial nutrition and IV fluids may be termed legal if death is not expected to kick in for a couple of months and any form of withdrawal or withholding of artificial nutrition and IV fluids leads to the cause of the patient’s death.
Another crucial aspect is advanced directives which exist as ways that ensure that the wishes and values of the patient are respected in essential and very important decisions which have to be made on behalf of the patient if they’re unable to make the decision themselves (Cook et al. 2013, 1383-1384).
There exist two different types of advanced directives whereby in the first place, the patient is responsible for choosing the right person they would please to make the decisions for them, or there’s a provision of instructions above the decisions the patient wishes to be made with the description of beliefs and values that will guide the decision-maker on what the patient would have wanted in such a situation. In different parts of Canada reason availability of the first kind whereas in some they allow for both.
Advance directives come in handy since the patient can decide in their right mind given impending incompetence and inability to speak, for instance, the involvement in a car accident.
The Canadian courts have ordered health care providers and doctors always to respect valid advanced directives. A statement from the Ontario Court of Appeal dictates that “a doctor does not have the freedom to disregard a patient advance instruction any more than he would be free to disregard instruction given at the time of the emergency.”
In Fleming vs Reid, A good case tried at the same court of appeal states “that a patient in anticipation of circumstances wherein he or she may be unconscious or otherwise incapacitated and unable to contemporaneously express her wishes about a particular form of medical treatment, we specify in advance his or her refusal to consent the proposed treatment. The patient tried to forgo treatment in the absence of some overriding social interest is paramount to the doctors’ obligation to provide medical care. This right must be honored even though the treatment may be beneficial or necessary to preserve the patient’s life or health and regardless of how ill-advised the patient’s decision may appear to others.”
It is essential to recall that Canadian law and Quebec do not facilitate citizens to ask for MAiD as a form of advance directive. Additionally, provinces and territories allow patients to state in advance the type of medical treatment and palliative care as well as personal care they’d wish to have or not have, such as artificial hydration and nutrition with oral liquids and oral feeding (Cook et al. 2013, 1383-1384).
The final aspect of the end-of-life policy and law in Canada is medical assistance in dying, legal throughout Canada. Notably, the first MAID legislation was enacted on June 17th, 2016, followed by amendments enacted on March 17th, 2021. Firstly we define MAiD as any form of help provided by a nurse or doctor and other practitioners to a patient’s request that leads to the patient’s death. It takes place in two distinct ways, which include the administration of a drug to the patient by a doctor practitioner leading to the patient’s death and the prescription of drugs to a patient by nurses or doctors or any other medical practitioner at the patient’s request so that the patient may ingest to enable their death.
For patients to access medical assistance in dying, they must be fully eligible to be accounted for by Canada’s health care services president. Secondly, they should be above 18 years and of sound mind capable of decision making about their health. The patients should have voluntarily asked for medical assistance in dying by themselves without external pressure. Additionally, there should be exposure and debriefing about some alternative ways that may help relieve suffering and pain, inclusive of palliative care. The patient must have provided informed approval to acquire medical assistance in dying, and lastly and most importantly, the patient must have an irremediable medical condition.
The provision of the above aspect is intended to help us analyze the cases, which helps us infer a logical conclusion as seen in the various court rulings in the Canadian laws and policies on the end of life care as seen in the previous segment above.
The first case is between Michelle versus Johnson. In this case, in early 2019, Mr. Justice Hayden was involved in a monumental court case that entailed a court ruling in favour of the approval of treatment withdrawal by the doctor, which is meant to serve as the end of life procedure for the 70-year-old woman who was facing the eventual stages of multiple sclerosis.
One obscure fact from the ruling of the court was the lack of clarity on whether the verdict made by Mr. Justice Hayden was done in the patient’s best interest. Reports by medical experts showed that the 70-year-old woman was subject to excruciating pain and had to endure severe respiratory constraints whenever she gasped for every breath.
To comprehend whether the doctor’s decision was legal or illegal, it is mandatory to refer back to the prerequisite conditions that must be met for a doctor to withdraw or withhold treatment without the patient’s consent. As seen in this case, the doctor approves the withdrawal of treatment channelled towards the 70-year-old woman without the patient’s consent or the substitute decision-maker. Heading to the Canadian end of life policy and legislative laws, the doctors did not have in their power the authority to approve the withdrawal of treatment.
Ironically, the court under Mr justice Hayden validated the doctor’s decision to withdraw treatment since the reports by medical experts showed that the patient was momentarily undergoing excruciating pain and struggled to take every single breath given her chronic illness and endurance she was undergoing their final stages of multiple sclerosis.
As much as Canadian policies and laws on the end of life care dictate that a doctor cannot withdraw treatment, Mr. Justice Hayden approves the doctor’s call. Consequently, this leads to a legal problem that leads to more questioning on the legality of a doctor’s withdrawal of treatment without the patient’s consent. And the other hand, if we were to look at some of the reasons that might have led Mr. Justice Hayden to rule in favour of the doctor, the patient was facing an impending death looming around the corner in a matter of days even weeks to come. Therefore, the assisted withdrawal of treatment by the doctor did not have any impact on hastening the death or causing the patient’s death in an unprecedented manner. Therefore, the court ruling indicates that a doctor has the authority to approve or concern to withdrawal or withholding of a patient’s treatment given the patient’s medical condition, especially if the patient is undergoing excruciating pain and suffering due to the disease.
The second case that we will look at involves Bury Stevens versus Allison Chaplin. The case is between two relatives, Bury and Allison, where the former is the uncle to the latter since he is a brother to the patient Allison’s mom. In this case, the ruling judge ruled in favour of withdrawal of treatment from a 90-year-old woman who had fallen into a minimally conscious state after falling down the staircase, which led to her sustaining an aneurysm. In this case, the judge was faced with a request to stop medical treatment by the doctors as per the patient’s daughter. Claims to back up the request included allegations that any form of prolonging life would only cause existence that lacked a good quality of life (Yarnell et al. 2017, 1479-1488).
On the contrary, the patient’s brother was not in support of Allison’s claims or interests. The patient resided in Alberta when she fell from the staircase, after which she endured recurring headaches. As a result, CT scans had to be carried out, and they revealed an aneurysm that had preceded the patient’s withdrawal into a minimally conscious state. Nine months after the incident, the patient had been put in a high dependency hospital ward where she was relentlessly receiving nutrition via clinical aided methods such as artificial hydration and artificial nutrition via nasogastric tubes. The daughter’s request was for the court to approve the withdrawal of treatment with subsequent provision of palliative care in hospice. As part of the court’s ruling, Mr. Justice Hayden ruled in favour of that treatment withdrawal after thoroughly listening to and contemplating evidence brought forth by all parties and medical experts.
As seen in this case, the main area leading to the contention experience is whether the judge should approve palliative care for the patient as for the request done by her daughter. Based on the Canadian laws and policies and end-of-life care, it is clear that continuous and deep sedation without artificial nutrition is probably legal when a patient is close to death. As stated earlier, close to death implies pending death in a matter of weeks, and therefore, any withdrawal or withholding of treatment would be deemed unlikely to lead to the cause of the patient’s death.
Applying the above law end of life policy to this case, it is clear that given the patient’s medical condition after falling into a minimally conscious state and being put under artificial support and artificial nutrition for about nine months, additionally backed up by medical reports that showed that she had to struggle for every breath that she took, is clear evidence that her case was either a very close to death or close to death scenario which allows any the application of palliative care and sedation as per the request made by her daughter.
Therefore it is beyond reasonable doubt that Mr. Justice Hayden acted according to the law when he ruled in favour of the withdrawal of treatment despite opposition from the patient brother.
Conclusion
Given the analysis of the two cases above, it is beyond reasonable doubt that certain requirements need to be met before a court makes a ruling in favour of the end of life care application or utilization (Costante et al. 2019, 10-12). In the first case, it was clear that the withdrawal of life-sustaining treatment laws and policies on the end of life allows a doctor to consent to withhold and withdraw any form of treatment, as seen by the ruling made by the court. Therefore, as much as there was the presence of underlying obscurity and confusion when it came to the legality of the use of withdrawing and withholding potential treatment as a means of the end of life care, it is now clear that doctors may approve the withholding if the patient’s medical condition is chronic or beyond any form of repair or medication assistance.
Also, as seen in the case of Bury vs Allison, it is clear that care is legal and maybe opted for, as seen from the ruling made by the Ontario Supreme Court under Mr. Justice Hayden. After analysis of the patient’s condition and the realization that the patient’s case was deemed close to death or very close to death, it allowed for palliative care and hospice to alleviate any form of pain and suffering (Collier 2011, 87-88). Additional information on the case shows that the patient’s husband had previously opted for such, and the patient had currently backed up his spouse’s decision and fully endorsed his choices. This form of the previous endorsement to palliative care acts as an implicates an advance directive that shows the inclination of the patient’s decision towards the suitability of the request made by her daughter to use palliative care and hospice.
In a nutshell, as seen from both cases, it is clear that for a court of law to rule in favour or against the use of end-of-life care in Canada, the parameters provided for under the end-of-life care policies and laws must be met and abide by to it too strictly. Hence we can conclude that the application of end of life care policy comes across as streamlined and still in the preliminary stages, which allows for further revision and addition of aspects such as the legalization of a doctor to approve the withdrawal of treatment without the consent of the patient or a close relative as substitute decision-maker if the patient’s medical condition mandatory demand for the end of life care to relieve the patient from any form of agony and anguish due to pain and suffering.
Therefore it should be clear that end of life care policy is a contentious and contradictory aspect of Canadian law that needs to be applied with much care and caution to avoid misuse and malpractice through manipulation for malicious purposes.
It would serve scholars if much research were undertaken to enable a total demystification and possible alleviation of obscurity and confusion that arise as after-math effects. Additionally, the Canadian judicial system opts to employ more efforts on the issue of end-of-life care, which seems to be a matter that affects practically a quarter of the Canadian population.
References
Fowler, Robert, and Michael Hammer. “End-of-life care in Canada.” Clinical and Investigative Medicine (2013): E127-E132.
Cook, Deborah, Graeme Rocker, and Daren Heyland. “Enhancing the quality of end-of-life care in Canada.” CMAJ 185, no. 16 (2013): 1383-1384.
Yarnell, Christopher J., Long Fu, Doug Manuel, Peter Tanuseputro, Therese Stukel, Ruxandra Pinto, Damon C. Scales, Andreas Laupacis, and Robert A. Fowler. “Association between immigrant status and end-of-life care in Ontario, Canada.” Jama 318, no. 15 (2017): 1479-1488.
Costante, Alicia, Christina Lawand, and Clare Cheng. “Access to Palliative Care in Canada.” Healthcare Quarterly (Toronto, Ont.) 21, no. 4 (2019): 10-12.
Collier, Roger. “Access to palliative care varies widely across Canada.” (2011): E87-E88.
write