TORONTO — The college that regulates Quebec doctors will soon provide practitioners with detailed guidelines — including what drugs to use — for euthanizing terminally ill patients who seek help to end their lives.
But it's unclear whether other provinces and territories will adopt a similar practice when doctor-assisted death becomes legal across the country early next year.
With the passage of Bill 52 in June 2014, Quebec became the first jurisdiction in Canada to legalize medical aid in dying for mentally competent patients who meet a strict set of criteria. The law goes into effect in December, allowing physicians to begin helping patients with an incurable condition and intolerable physical or psychological suffering to die.
In February, doctors across the country will also be able to provide aid in dying to patients, following the Supreme Court of Canada's groundbreaking decision earlier this year that overturned the legislative ban on the practice.
Dr. Yves Robert, secretary of the College des medecins du Quebec, said the regulatory body has developed a guide that shows doctors how to end a patient's life with sequential injections of three medications: a sedative such as a benzodiazepine to relieve anxiety, a barbiturate or similar drug to induce a coma, and finally a neuromuscular block, which stops the heart and respiration.
The step-by-step instructions also tell doctors what dosages of the medications to use, where to inject the drugs and what to do should complications such as vomiting or an allergic reaction occur.
Robert said euthanasia kits will be prepared by pharmacists based on the physician's prescription. Each kit will contain enough drugs and injection equipment for two euthanasia procedures, in the event a backup set is needed. Doctors must return any unused medication to the pharmacy.
Dr. Cindy Forbes, president of the Canadian Medical Association (CMA), said it's too early to say whether regulatory colleges in other provinces and territories would follow Quebec's lead in creating similar guidelines for lethal injection.
"The major issue right now is one of timing and the fact that there's no provincial legislation or regulations in place," Forbes said Tuesday. "Each province and all the colleges are looking at what role they will play as well, and I don't think it's really clear right now."
When the Supreme Court threw out the law that criminalized physician-aided death last February, it stayed its decision for a year to allow the Harper government time to craft and pass replacement legislation. But the federal election campaign has put any efforts in that direction on hold until after Canadians go to the polls Oct. 19.
The CMA has said it will offer training to doctors who choose to participate in assisted death and it's calling for national standards to prevent a hodgepodge of regulations due to provinces and territories going their own way, based on how each interprets the high court ruling.
"It's going to be necessary at some point for physicians to be following the best practices and have clinical guidelines," said Forbes. "So I think when the time comes, as long as we have those standards, that's going to be the most important thing.
"Obviously Quebec has looked at this and is moving ahead in this manner, but there needs to be a unified approach across the country."
Robert said the guidelines were developed after the college reviewed processes used by the Netherlands and other countries where doctor-assisted death is legal. The document will be posted on a secure part of the college's website in French on Sept. 10, followed by an English version about a month later.
Doctors in Quebec will also be provided with training to provide the life-ending procedure, which could involve nurses and other practitioners. However, only a physician can administer the actual injection, he said.
"We insist on the fact that this is a medical act. Others may help, but the law authorizes only physicians to do the procedure."
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A look at some jurisdictions where right-to-die laws are in place. (Information courtesy of The Canadian Press)
A right-to-die bill was adopted last year, the first legislation of its kind in Canada. The law, scheduled to go into effect in December, stipulates that patients would have to repeatedly ask a doctor to end their lives on the basis of unbearable physical or psychological suffering. They would have to be deemed mentally sound at the time of the requests. The law, however, is being challenged in court by two Quebec-based groups on the grounds that it undercuts sections of the Criminal Code that outlaw assisted suicide and euthanasia. The federal government has expressed its opposition to the legislation but is named as a defendant in the court challenge because it is responsible for the Criminal Code.
The results of a referendum made Oregon the first U.S. state to make it legal for a doctor to prescribe a life-ending drug to a terminally ill patient of sound mind who makes the request. However, doctors cannot administer the life-ending drugs and the patient must swallow them without help. Patients must state three times -- once in writing -- that they wish to die, and those statements must be made at least 15 days apart. They must also obtain a concurring opinion from a second doctor that they have less than six months to live and are of sound mind. The law took effect in late 1997, and through June, 2014, just over 800 people had used the law.
The state became the first in the U.S. to allow a person's right to die through legislation rather than through a court decision or a referendum result. Vermont's law, which took effect in May 2013, is closely modelled on the system in Oregon and uses the same safeguards. Patients must state three times, including once in writing -- that they wish to die. They must also obtain a concurring opinion from a second doctor that they have less than six months to live and are of sound mind.
In January 2014, a judge ruled that competent, terminally ill patients have the right to seek their doctors' help in getting prescription medication if they want to end their lives on their own terms. The state's attorney general is appealing the ruling, and a decision on whether it will be upheld is expected later this year.
A referendum saw the state enact right to die legislation in 2008. As in Oregon, patients with less than six months to live must administer the doctor-prescribed lethal medication on their own. According to a government report, 549 people applied for the right to die between 2009 and 2013. Of those, 525 actually took their own lives.
In 2009, the state's Supreme Court ruled that Montana's public policy supports mentally competent, terminally ill patients being able to choose aid in dying. Physicians are allowed to prescribe medication that patients must administer themselves. More detailed legislative bills have been introduced in the state but have not passed. The court ruling still stands today, but data about its usage is not available.
A law passed in 1942 forbade anyone from helping someone kill themselves for selfish reasons. As a result, people arguing that they are assisting with a suicide for unselfish motives are not considered to be committing a crime. Suicides can be assisted by people other than doctors and no medical condition needs to be established. Switzerland is the only country that allows foreigners to travel there for the purpose of ending their own lives.
In the Netherlands, euthanasia is legal under specific circumstances and for children over the age of 12 with parental consent. In Europe, patients don't have to prove that they have a terminal illness -- establishing unbearable suffering is usually sufficient. Dutch doctors are allowed to perform euthanasia if a patient whose unbearable suffering has no hope of improvement asks to die with a full understanding of the situation. A second doctor must agree with the decision to help the patient die.