Euthanasia doctor developed Ontario Covid-19 triage guidelines

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr James Downar, the former chair of the physicians advisory committee for Dying with Dignity, a Canadian euthanasia lobby group, developed the "triage protocol" for doctors who may be forced to make difficult ethical treatment decisions if hospitals become overwhelmed by the Covid-19 outbreak.

Jennifer Yang reported on March 29 that the Toronto Star obtained a copy of the document that is based on rationing critical care beds and ventilators. The document establishes policies concerning life or death choices.

When contacted by Yang for comments, Downar said he was referring all media requests to Ontario Health, which was unable to respond by deadline.

According to Yang, the document states:

The system will be triggered only if local resources have been depleted and every attempt has been made to relocate patients to other facilities that still have capacity. The document acknowledges, however, that “transportation resources will become stretched in a pandemic and this will not always be possible.”

Yang describes the Triage protocol:

Under the triage protocol, patients will be assessed according to both inclusion and exclusion criteria. Those who are excluded from treatment will be patients “who are very likely to die from their critical illness, and people who are very likely to die in the near future even if they recovered from their critical illness.”

At level 1 triage, for example, doctors are advised to exclude patients who have greater than 80 per cent predicted mortality. At level 3, patients with greater than 30 per cent predicted mortality will be excluded. Under the triage protocol, long-term-care patients who meet specific criteria will also no longer be transferred to hospitals.

Patients who no longer meet the criteria for care under the triage system will be removed from life-saving interventions like ventilation or not have them offered, according to the protocol. But this does not mean these patients will stop receiving medical treatment or care. They will also receive “the highest priority for palliative care.”

Decisions as to who will receive treatment and who will not receive treatment are difficult, but the protocol is illegal. In Ontario court decisions have determined that decisions to provide or to stop treatment require the consent of the patient or the patients healthcare advocate. Therefore to remove a patient from life-saving intervention, even with good intention, cannot be done without consent.

Yang then states that patients who are withheld or withdrawn from treatment will receive palliative care. She states:

Patients who no longer meet the criteria for care under the triage system will be removed from life-saving interventions like ventilation or not have them offered, according to the protocol. But this does not mean these patients will stop receiving medical treatment or care. They will also receive “the highest priority for palliative care.”

Yang then concludes the article by stating that the protocol outlines three guiding principles for the triage protocol:

the first being “utility,” meaning physicians should allocate resources to patients who stand to benefit the most. 

The second is “proportionality” — in other words, the number of patients who will be negatively affected by this last-resort triage system should not exceed the number of people who stand to benefit. 

The third principle is fairness, meaning only clinical information should be used to decide which patients are treated over others. “Priority should not be given to anyone on the basis of socioeconomic privilege, or political rank.”

It is sad that the rules for withdrawing treatment are being developed from a utilitarian point of view and without considering the legal ramifications of their decisions.

Is the Netherlands refusing to treat elderly Covid-19 patients.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

An article by Salvador Aragonés published by Aleteia.org claims that the Netherlands is rationing healthcare by denying treatment to patients based on age. Aragonés also claims that the Netherlands is blaming the financial crisis in Italy and Spain as caused by their medical treatment policy. Aragonés writes (google translated);

A great scandal is caused in Europe, and not only in Europe, with the systematic attitude of the Netherlands in treating coronavirus patients in their territory by age, even before their hospitals are full. 

According to statements by Dr. Frits Rosendaal, head of clinical epidemiology at the Leiden University Medical Center, and a member of the Royal Dutch Academy of Sciences and Art, with many awards and recognized merits. This well known doctor in the Netherlands is now battling the coronavirus, comments on how hospital admissions for the Covid-19 virus are followed in the Netherlands, while criticizing the way of life of Italy and Spain. 

The doctor (Rosendaal) said: “In Italy, the ICU capacity is managed very differently [from the Dutch]. They admit patients that we would not include because they are too old. The elderly have a very different position in Italian culture." He (Rosendaal) does not understand how in these southern European countries they admit “old people to the ICU”. The Netherlands does not hospitalize the weak and the elderly in order to make room for young people. He attributes it to a “cultural difference” between the Netherlands and the Latin countries.

Aragonés links the Dutch policy of not treating elderly Covid-19 patients with euthanasia. He states (google translated):

...in the Netherlands as in Belgium, euthanasia has been applied for years, according to the authorities, “voluntary”. However, in Germany, and in France, Spain and Italy, they have received elderly patients from these countries to be cured, not of coronaviruses, but of anything, because they do not trust the hospitals of their country: euthanasia is not Voluntary, they say, nor is it respected - not infrequently - the will of the person to whom euthanasia is applied.

Aragonés then states that Dutch finance minister Wopke Hoekstra is urging the European parliament to investigate "wasted finances" in Portugal and Spain related to Covid-19.

Treatment and care related to the Covid-19 has clearly affected relations between European nations.

On March 28, the US Department of Health and Human Services (HHS) published a bulletin upholding the equality and human rights of people with disabilities and the elderly concerning treatment decisions and healthcare allocation.

US Department of Health and Human Services will uphold human rights in relation to health care resource allocation.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The US Department of Health and Human Services (HHS) issued a bulletin on March 28 concerning the provision of healthcare during the Covid-19 crisis.
 
Disability rights groups, and others, challenged the healthcare orders that have been issued by several states, including Alabama and Washington State, denying human rights and equality of people with disabilities, if healthcare rationing is deemed necesary during the Covid-19 crisis.

The healthcare rationing debate is not limited to the United States. Fritz Rosendaal, an epidemologist in the Netherlands is quoted in an article by Salvador Aragonés published by Aleteia.org as stating (google translated):

“In Italy, the ICU capacity is managed very differently [from the Dutch]. They admit patients that we would not include because they are too old. The elderly have a very different position in Italian culture." He does not understand how in these southern European countries they admit “old people to the ICU”. The Netherlands does not hospitalize the weak and the elderly in order to make room for young people. He attributes it to a “cultural difference” between the Netherlands and the Latin countries.

Sheri Fink, writing for the New York Times, wrote an excellent article on the HHS bulletin and the healthcare protocols that led to complaints by the disability community. Fink quotes Roger Severino, the director of the HHS office responding to the release of the bulletin, as stating:

“Our civil rights laws protect the equal dignity of every human life from ruthless utilitarianism,”.. “Persons with disabilities, with limited English skills and older persons should not be put at the end of the line for health care during emergencies.”

Fink writes that Severino was responding to several complaints. She states:

Mr. Severino said in an interview that in response to multiple complaints, his office was opening the investigations to ensure that state-mandated rationing plans “are fully compliant with civil rights law.” He said his office had heard from “a broad spectrum of civil rights groups, pro-life groups, disability rights groups, from prominent members of Congress from both sides of the aisle, from ordinary people who are concerned about their civil rights in this time of crisis.”

Ari Ne'eman

Ari Ne'eman, a disability rights scholar who comments on the HHS bulletin. Ne'eman states that there was “urgent need for comprehensive guidance.” Fink quotes Ne'eman as stating:

Some (State) plans instruct hospitals not to offer mechanical ventilators to people above a certain age or with particular health conditions.

In Alabama’s plan, people with “severe or profound mental retardation” as well as “moderate to severe dementia” should be considered “unlikely candidates for ventilator support” during a period of rationing. Washington’s guidance recommends that triage teams consider transferring hospital patients with “loss of reserves in energy, physical ability, cognition and general health” to outpatient or palliative care.

In defense of the Washington State rationing plan, Fink quotes Dr Kathy Lofy, the health officer of Washington State:

“The guidance in Washington around managing scarce resources during emergencies was largely designed to avoid discrimination during the allocation of scarce resource and involves a regional team to ensure resources are being allocated in a fair way,”

The Alabama Health Department is quoted by Fink as stating:

the state’s ventilator triage guidelines had been “greatly misunderstood” and were “solely intended as a tool for providers” making difficult choices. The statement said the document, which remained on its website on Saturday, was over a decade old and had since been replaced by a more comprehensive set of guidelines for health care emergencies. Those newer guidelines did not address ventilator triage, but said that the allocation of care should not be discriminatory.

Fink explains that disability rights groups were concerned because people who required long-term use of a ventilator might have been removed from the ventilator based on these state protocols. She writes

The plans typically include protocols for removing ventilators from people after a certain time period if they do not appear to be improving. In some states, including New York, people who required ventilators long-term, such as those who have certain spinal cord injuries, could be subject to having their ventilators reassigned under the protocol if they were admitted to hospitals during the crisis.

Many of the plans, even if they do not include outright age restrictions, consider stage of life as a factor in assigning ventilators or critical care beds. The civil rights office’s new statement might put that into question.

Fink quotes Severino's, who assures Americans that human rights laws will be upheld during the Covid-19 crisis:

If the country reached a point where health care rationing standards would be applied, “those standards must comply with civil rights laws.”

“Ultimately the question as to resource allocation is not a scientific or medical one,”

“It is ultimately a moral and legal one.”

Ne'amen is quoted as stating:

“enforcement of our civil rights laws should never be called into question, even in the context of an emergency.”

Fink ends her article with a promise from Severino:

“I want to make sure in this time of crisis, we don’t forget the foundational principles that are part of what makes America so special,”

“That we do care for everybody, that every person in America deserves equal dignity and respect.”

“Our response will be a reflection of our national character.”

Even in a crisis, human rights and equality must be maintained.

Euthanasia (MAiD) is not an essential service during Covid-19 crisis.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Kelly Grant, the health reporter for the Globe and Mail, reported on March 27 that at least two regions in Ontario have stopped doing euthanasia during the Covid-19 crisis since it is not an essential service and the need to conserve healthcare services.

According to Grant, the Ottawa and Hamilton regions have temporarily stopped providing euthanasia "MAiD services" during the Covid-19 pandemic. Grant wrote:

The Champlain Regional MAID Network, which serves Ottawa and the surrounding area, issued a notice on Wednesday that it was shutting down the service in hospitals and homes to prevent the transmission of COVID-19 and to conserve health-care resources. 

Hamilton Health Sciences, a hospital network with 10 sites, has also stopped providing assisted dying within its walls.

Grant reported that in the Hamilton region:

Several of the hospital network’s MAID providers have already been redeployed and elective procedures of all kinds are being delayed to make room for an expected surge of coronavirus patients.

While in Ottawa, Grant reported that the Champlain Regional Medical Assistance in Dying Network sent out the following bulletin:

“After careful consideration of the principles to prevent COVID-19 transmission and conserve health-care resources, and in alignment with the provincial ramp-down of elective services, effective immediately, we will not be providing community MAiD procedures or in-patient procedures at The Ottawa Hospital,” 

“Additionally, our partners at Home and Community Care will not be in a position to provide nursing support for independent practitioners who wish to provide MAiD in the community.”

Killing people by lethal injection is not healthcare. Canada's MAiD (euthanasia and assisted suicide) law creates an exception in the criminal code to homicide. Since it is a criminal code statute it is technically not healthcare, therefore it cannot be an essential healthcare service.

The euthanasia clinic in the Netherlands also announced that it has temporarily shut-down due to healthcare priorities during the Covid-19 crisis.

But in Victoria BC and the Toronto region euthanasia (MAiD) has been deemed an essential service. Grant reports:

Stefanie Green, a Victoria doctor and the president of the Canadian Association of MAID Assessors and Providers (CAMAP,) said the health authority on Vancouver Island has also deemed assisted dying an essential service.

Killing is not healthcare.

Margaret Dore: (New Jersey) Euthanasia Act "Must Be Set Aside"

This article was published by Choice is an Illusion on March 27, 2020.

Margaret Dore

On March 24, 2020, a hearing was held in Glassman v Grewal, a lawsuit, which seeks to invalidate New Jersey's euthanasia law, formally known as the "Medical Aid in Dying for the Terminally Ill Act."

The specific matter before the court was a motion to dismiss brought by the defendant, New Jersey Attorney General, Gurbir S. Grewal.

The plaintiff, Joseph Glassman, represented by E. David Smith, opposed the motion, as did Margaret Dore, president of Choice is an Illusion, representing herself as amicus curiae.

Dore, who had filed both an amicus brief and a reply brief, argued that the Act must be set aside pursuant to the New Jersey Constitution. Her arguments largely tracked her reply brief, a portion of which is set forth below.

The Court took the matter under advisement.

* * *

Reply Brief Excerpt (web version):

B. The Act’s Title Is Misleading and Therefore Unconstitutional

The Act’s title, the “Medical Aid in Dying For the Terminally Ill Act,” implies that the Act is limited to the “dying” and the “terminally ill.”[6] As described in Dore’s amicus brief, the Act also applies to people with years or decades to live.[7] For this reason alone, the title is misleading and therefore unconstitutional. The Act must be set aside.

C. Contrary to the Attorney General, the Act Allows Euthanasia

Euthanasia as traditionally defined is the administration of a lethal agent by another person.[8] The Attorney General claims that the Act does not allow euthanasia.[9] This claim is wrong for the following reasons:

1. The Act’s name means euthanasia The Act’s name, “Medical Aid in Dying for the Terminally Ill Act,” contains the phrase “Aid in Dying.”

Aid in Dying is a traditional euphemism for active euthanasia. See, for example: Craig A. Brandt, Model Aid-in-Dying Act, Iowa Law Review, 1989 (“Subject: Active Euthanasia ....”)[10]

For this reason alone, the Act allows euthanasia.

2. The Act allows euthanasia as traditionally defined The Act refers to the lethal dose as “medication.”[11] Generally accepted medical practice allows other people, including doctors and adult children, to administer medication.[12]

If the medication administered is a lethal dose, this is euthanasia as traditionally defined.

3. The Act does not require self-administration. The ADA would trump any such requirement Nothing in the Act says that self-administration is required.[13] If it were, the Americans with Disability Act [ADA] would trump the requirement to allow euthanasia for people unable to self-administer.[14] For this reason also, the Act allows euthanasia as traditionally defined.

D. Voluntariness Is Not Assured

The Attorney General claims that the Act is “strictly voluntary” for patients, which is not true.[15] As previously discussed in Dore’s amicus brief, a more obvious reason is the Act’s complete lack of oversight at the death.[16] If the patient objected or even struggled, who would know?

E. Purported Patient Protections Are Illusory

The Act sets forth patient protections, including a formal application process to obtain the lethal dose.[17] Per the Act, the attending physician:

shall ensure that all appropriate steps are carried out in accordance with the provisions of [the Act] before writing a prescription for [the lethal dose].[18] 

The Act does not define “accordance.”[19] Dictionary definitions include “in the spirit of,” meaning “in thought or intention.”[20] With these definitions, the physician’s mere thought or intention to comply with patient protections is good enough. Actual compliance is not required. Purported patient protections are illusory.

F. Deaths in Accordance With the Act Are “Natural” as a Matter of Law.

1. Action taken in accordance with the Act is not suicide or homicide The Act states:

Any action taken in accordance with the provisions of [the Act] shall not constitute ... suicide ... or homicide under any law of this State.[21]

2. The Act requires deaths to be reported as “natural” In New Jersey, death certificates have five categories for reporting the manner of death, four of which are substantive: (1) natural; (2) accident; (3) suicide; and (4) homicide.[22] The fifth category is “undetermined.”[23]

As noted in the preceding section, a death occurring in accordance with the Act does not constitute suicide or homicide under any law of the State. The death is also not an accident due its having been an intended event. This leaves “natural.” Deaths occurring pursuant to the Act are natural as a matter of law.

G. Dr. Shipman and the Call for Death Certificate Reform

Per a 2005 article in the UK’s Guardian newspaper, there was a public inquiry regarding Dr. Harold Shipman, ... determining that he had “killed at least 250 of his patients over 23 years.”[24] The inquiry also found:

that by issuing death certificates stating natural causes, the serial killer [Shipman] was able to evade investigation by coroners. (Emphasis added).[25] 

Per a subsequent article in 2015, proposed reforms included having a medical examiner review death certificates, so as to improve patient safety.[26] The New Jersey Act has instead moved in the opposite direction to require that deaths be reported as natural. Doctors and other perpetrators have been enabled to kill under mandatory legal cover.

H. The Act Renders New Jersey Residents Sitting Ducks to Their Heirs and Other Predators

New Jersey’s slayer statute prevents a killer from inheriting from his or her victim. The statute states:

[A]n individual who is responsible for the intentional killing of the decedent forfeits [his or her inheritance].”[27] 

The rational is that a criminal should not be allowed to benefit from his or her crime.[28]

Under the Act, however, a person who intentionally kills another person is allowed to inherit. This is due to the deaths being certified as natural. With the passage of the Act, New Jersey residents with money, meaning the middle class and above, have been rendered sitting ducks to their heirs and other predators.

Footnotes:
....

[6] The Act, N.J.S.A. 26:16-1, attached in the appendix at p. A-2.
[7] Dore’s Amicus Brief, dated 12/19/19, Section IX, pp. 6 to 8.
[8] AMA Code of Medical Ethics Opinion, 5.8, in the appendix at page A-17. (“Euthanasia is the administration of a lethal agent by another person....”).
[9] The Attorney General’s letter brief, dated February 4, 2020, page 8, states:
Dore’s argument that the Act violates the single object rule is premised on her misstatement that the Act permits involuntary participation and euthanasia. (Emphasis added). [10] Georgetown University information pages, summarizing the Brandt and CeloCruz articles, in the appendix at pages A-18 and A-19.
[11] The Act, attached in the appendix, at pages A-2 through A-16, referring to the lethal dose as medication throughout its text.
[12] Dr. Kenneth Stevens states:
Generally accepted medical practice allows a doctor, or a person acting under the direction of a doctor, to administer prescription drugs to a patient.
Common examples of persons acting under the direction of a doctor, include: ... adult children who act under the direction of a doctor to administer drugs to their parents in a home setting. Declaration of Kenneth Stevens, MD, attached in the appendix at pp. A-20 to A-22, quote at page A-22, ¶ 10 (spacing changed).
[13] See the Act in its entirety, attached in the appendix, at pp. A-2 through A-16.
[14] Dore’s Amicus Brief, pp. 10-11.
[15] The Attorney General‘s letter brief, dated February 4, 2020, page 8.
[16] See the Act in its entirety, in the appendix at pp. A-2 to A-16.
[17] The Act, in the appendix at pp. A-4 through A-8.
[18] Id., in the appendix, at page A-5.
[19] See the Act in its entirety, in the appendix, at pp. A-2 through A-16.
[20] Definitions attached in the appendix at pp. A-24 and A-25.
[21] The Act, C.26:16-17.a.(2), attached in the appendix at page A-10.
[22] Andrew L. Falzon, MD, and Sindy M. Paul, MPH, “Death Investigation and Certification in New Jersey,” MD Advisor, a journal for the New Jersey medical community, 2016. (Attached in the appendix at page A-25)
[23] Id.
[24] David Batty, “Q & A: Harold Shipman,” The Guardian, 08/25/05, at https://www.theguardian.com/society/2005/aug/25/health.shipman. (Attached in the appendix at pages at A-26 to A-28).
[25] Id., attached at A-28.
[26] Press Association, “Death Certificate Reform Delays ‘Incomprehensible,” The Guardian, January 21, 2015, attached in the appendix at A-29 to A-30.
[27] NJ Rev Stat § 3B:7-1.1, attached in the appendix at pages A-31 and A-32.
[28] Cf. Ilene S. Cooper and Jaclene D'Agostino, "Forfeiture and New York's 'Slayer Rule', NYSBA Journal, March/April 2015

Death doctors use Covid-19 crisis to permit "aid-in-dying" via telehealth.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

The assisted suicide lobby are actively promoting the approval of assisted suicide and euthanasia via telehealth. The death lobby are using the coronavirus to achieve two main goals, that being, allowing the approval of lethal prescriptions via telemedicine or telehealth and the expansion of assisted suicide to include euthanasia.

If allowed, a person could be prescribed lethal drugs for assisted suicide without ever being examined by a doctor.

According a committee of the newly formed American Clinicians Academy on Medical Aid in Dying, (death doctors) (chaired by Lonny Shavelson, a California doctor who only offers death) the coronavirus crisis requires allowing approvals by telehealth. The committee stated:

In light of the coronavirus crisis, a committee has been convened to establish recommendations pertaining to the use of telemedicine to evaluate patients’ requests to consider medical aid in dying. (See below for members of the policy committee.)

For the purposes of this policy statement, “telemedicine” and/or “telehealth” refers to a visual and verbal patient contact by electronic means, without an in-person visit. 

Long before the onset of the coronavirus pandemic, many established aid-in-dying clinicians used telemedicine visits to evaluate select aspects of terminally ill patients’ requests to consider medical aid in dying. Given the need to limit in-person contacts to decrease the speed of contagion of coronavirus, an increased use of telemedicine for select aspects of aid-in-dying evaluations and care is recommended.

The committee of death doctors concluded:

The Committee concludes that there is nothing inherent in an aid-in-dying request that prohibits or discourages the use of telemedicine.

The death doctors are using the coronavirus to achieve their goal and they have no intention of going back to examining patients, once the coronavirus crisis passes. 

It is important to recognize the language used by the death doctors. "Medical Aid in Dying" (MAiD) is a term that is used by the death lobby for euthanasia and assisted suicide. The American death lobby are trying to extend assisted suicide legislation to include euthanasia or lethal injection. Most new assisted suicide bills are not what they appear to be.

Recently I reported that another death lobby group was using the coronavirus to promote assisted suicide via telehealth.

This is not a new plan. The 2019 New Mexico assisted suicide bill included a telehealth provision and a recent bill to expand assisted suicide in Hawaii includes a telehealth provision.State regulators should not take this group seriously. These are death doctors promoting more death. In the case of Shavelson, he does not provide medical treatment only death.

Washington State assisted suicide group - death may take hours.

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

A Washington State assisted suicide lobby group is informing its "clients" that death by assisted suicide may take many hours. 

In their document, Death with Dignity - Preparing for the last day, End of Life Washington states:

Every individual is different and time to death after taking the medication varies greatly depending on the person’s physical condition and ability to absorb the medication. Be assured that once the person is in a coma (generally within 5-10 minutes of taking the life-ending medication), they will be in a peaceful place and not experience any suffering. If they do not die as soon as expected, do not panic. There is little that can be done except to wait. Caregivers may administer any of the medications in a hospice kit, if one is available, in response to any symptoms that ordinarily would be treated.

It may be helpful to consider the additional hours as a time for a vigil, which often occurs during the last hours of a person’s life during a natural death.

The Washington State 2018 assisted suicide report indicated that of the 203 reported assisted suicide deaths that there were 8 reported complications in 2018, likely related to the new DDMA and DDMP2 lethal drug cocktails. Also, 62 deaths reportedly took more than 90 minutes with the time of death ranging from 7 minutes to 30 hours.

The Oregon 2019 assisted suicide report states that the time of death ranged from 1 minute to 47 hours but the report didn't indicate how many people died more than 90 minutes after taking the lethal drugs.

The fact that assisted suicide deaths can take many hours is directly related to the new lethal drug cocktails that have been developed to enable a cheaper way to kill.

The new lethal drug cocktails were developed through human experimentation. The results of the first two failed lethal drug trials were:

The (first) turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain. The second drug mix, used 67 times, has led to deaths that stretched out hours in some patients — and up to 31 hours in one case.

In February 2019 I published the article - assisted dying can cause inhumane deaths based on research by Professor Jaideep Pandit that was published in the British Medical Journal. Pandit researched complications with assisted suicide and capital punishment deaths and indicates that the complications include:

• difficulty in swallowing the prescribed dose (up to nine per cent) and vomiting in 10 per cent, both of which can prevent proper dosing.
• Re-emergence from a coma occurred in two per cent of cases, with a small number of patients even sitting up during the dying process, the authors said. 
• After oral sedative ingestion, patients usually lose consciousness within five minutes. However, death takes considerably longer. 
• But in a third of cases, death can take up to 30 hours,

The negative outcomes associated with the lethal drug cocktails and the ethics of human experimentation related to the development of these drugs should be investigated by the US government, based on the controlled substances act.

Lethal Drugs Used For Assisted Suicide and Complications for Patients.

The Patients Rights Action Fund published the following information.
 
Warning: If you are experiencing suicidal thoughts, do not read this article but call: 1-800-273 (talk) 8255.

Article: Lethal drug cocktails experimented on humans (Link).

Seconal (Secobarbital)

• A 90-100 pill dosage of Seconal (secobarbital) was widely used for assisted suicides for many years until it became too costly and in 2019 became unavailable for this use. [1]
  

Phenobarbital

• To replace Seconal, proponents of assisted suicide began experimenting with combinations of drugs to induce death. One of the drug combinations used is a mixture consisting of phenobarbital, chloral hydrate and morphine sulfate. The patient mixes the powder with water, alcohol, applesauce or juice. This drug combination lowered the cost to $400-$500. 
• In Oregon, the phenobarbital combination was used to cause the death of 65 patients. For those cases for which data on time to death after ingestion were reported, patients experienced death from 20 minutes to 72 hours. [2]
  

DDMP 1; DDMP2

• Increasingly, experimentation began with other new drug cocktails. A combination using DDP (diazepam, morphine sulfate and propranolol) took a patient 18 hours to die so 10 mg. of digoxin was added to the mix to create DDMP 1. The digoxin dosage was subsequently increased to 15 mg. to form DDMP 2. [3] 
• Researchers have described DDMP 2 as “blue-whale-sized doses…..And the mixture tastes extremely bitter. ‘Imagine taking two bottles of aspirin, crushing it up, and mixing it in less than half a cup of water or juice.’” [4]  
• In Oregon, DDMP 1 and DDMP 2 accounted for 239 deaths through 2019. For those cases for which data on time to death after ingestion were reported, patients experienced death from a range of 5 minutes to 47 hours. Two patients regained consciousness after ingesting the drugs.[5] “The median time until death was longer for the DDMP2 compound (120 min) than for secobarbital (25 min)…”[6] The drug cocktail is taken in liquid form and is ingested orally or through a tube.
  

DDMA 

• In 2019, DDMA was introduced which is a combination of diazepam, digoxin, morphine sulfate and amitriptyline. In Oregon, DDMA was used for 87 patients and for those cases for which data on time to death after ingestion were reported, the time to achieve death ranged from one minute to 19 hours. [7]
  

Morphine Sulphate 

• In Washington State in 2017, 130 out of 196 deaths (63%) were attributed to use of morphine sulfate in isolation.[8] Deaths from secobarbital and morphine sulfate lasted from 5 minutes to 35 hours in range.[9]
  

General Complications From Lethal Drugs Used In Assisted Suicide Deaths

• Experimenting with combinations of drugs is “research” which has not been approved by any ethics review committee like an "Institutional Review Board" (IRB), which appears to violate research ethics standards. 
• According to The Atlantic: “No medical association oversees aid in dying, and no government committee helps fund the research…The doctors’ work {to experiment with drugs which kill patients} has taken place on the margins of traditional science. Despite their principled intentions, it’s a part of medicine that’s still practiced in the shadows.”[10]  
• According to Kaiser Health News: “The first Seconal alternative turned out to be too harsh, burning patients’ mouths and throats, causing some to scream in pain.”[11] “The second drug mix, used 67 times, has led to deaths that stretched out hours in some patients – and up to 31 hours in one case…the next longest 29 hours, the third longest 16 hours and some 8 hours in length.”[12]
•  According to the New England Journal of Medicine: “One in five Dutch patients using standard barbiturates to kill themselves experienced complications including vomiting, inability to finish the medication, longer than expected time to die, failure to induce coma, and awakening from coma.” [13]  
• According to Anaesthesia: “However, for all these forms of assisted dying, there appears to be a relatively high incidence of vomiting (up to 10%), prolongation of death (up to 7 days), and re-awakening from coma (up to 4%), constituting failure of unconsciousness. This raises a concern that some deaths may be inhumane…”[14]
•  According to the British Medical Journal: “Complications related to assisted dying methods were found to include difficulty in swallowing the prescribed dose (≤9%), a relatively high incidence of vomiting (≤10%), prolongation of death (by as much as seven days in ≤4%), and failure to induce coma, where patients re-awoke and even sat up (≤1.3%). ‘This raises a concern that some deaths may be inhumane,’ the researchers said. They had expected to find a single technique being used but said that ‘the considerable heterogeneity in methods suggests that an optimum method of achieving unconsciousness remains undefined.’” [15]
  

1. http://www.medscape.com/viewarticle/869023?src=emailthis#vp_2 https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year22.pdf, page 7

2. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year22.pdf, page 16

3. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf, page 15

4. https://www.theatlantic.com/health/archive/2019/01/medical-aid-in-dying-medications/580591/

5. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year22.pdf, page 16

6. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year21.pdf, page 7

7. https://www.oregon.gov/oha/PH/PROVIDERPARTNERRESOURCES/EVALUATIONRESEARCH/DEATHWITHDIGNITYACT/Documents/year22.pdfm , page 16

8. https://www.doh.wa.gov/Portals/1/Documents/Pubs/422-109-DeathWithDignityAct2017.pdf, page 9

9. https://www.doh.wa.gov/Portals/1/Documents/Pubs/422-109-DeathWithDignityAct2017.pdf, page 10

10. https://www.theatlantic.com/health/archive/2019/01/medical-aid-in-dying-medications/580591/

11. Kaiser Health News, “Docs in Northwest Tweak Aid-In-Dying Drugs to Prevent Prolonged Deaths”, February 21, 2017

12. Kaiser Health News, “Docs in Northwest Tweak Aid-In-Dying Drugs to Prevent Prolonged Deaths”, February 21, 2017

13. Groenewoud, J.H., van der Heide, A., Onwuteaka-Philipsen, B.D., Willems, D.L., et al. (2000). Clinical Problems with the Performance of Euthanasia and Physician-Assisted Suicide in the Netherlands. The New England Journal of Medicine, 342, 551-556.
 
14. Sinmyee, S., Pandit, V.J., Pascual, J.M., Dahan, A., Heidegger, T., et al. (2019). Legal and ethical implications of defining an optimum means of achieving unconsciousness in assisted dying. Anaesthesia, 74,557-559.

15. Torjesen, Ingrid. (2019) Assisted dying methods can lead to “inhumane” deaths. British Medical Journal. 364:1797 doi: 10.1136/bmj.1797

Dr Sonu Gaind: Canadian Psychiatric Association (CPA) position on euthanasia for psychiatric reasons is embarrassing

Alex Schadenberg
Executive Director, Euthanasia Prevention Coalition

Dr Sonu Gaind

Dr. K. Sonu Gaind is an associate professor of psychiatry at the University of Toronto, a past president of the Canadian Psychiatric Association (CPA) and a member of the Council of Canadian Academies expert advisory group on MAiD responds in the CanadianHealthcareNetwork.ca to the new position of the CPA supporting euthanasia.

Dr Gaind was the president of the (CPA) at the time of the Carter Supreme Court of Canada euthanasia decision. In response to the Supreme Court decision, the CPA held a task force, developed guidelines and provided evidence based guidance to policy makers and government committee's on euthanasia for psychiatric conditions.
 
In his recent article: I wish I didn't have to write this Gaind expresses his embarrassment by the new position by the CPA that that supports euthanasia for people with psychiatric conditions.

Gaind comments on his personal position on MAiD:

When I started all this, as CPA president in late 2015, I entered with an open mind and as neutrally as I could, both to respect my role as representing not just myself but all CPA members, and also on a personal level I did not want any pre-judgements to form my opinion without understanding the various issues and evidence. I am not a conscientious objector to MAiD in general, and in fact am physician chair of our hospital MAiD group, overseeing all the MAiD cases we undertake. However, after this extensive period of review, it is clear to me now that expanding MAiD for sole criterion mental illness would not be safe in the current context.

Gaind comments on how the euthanasia expansion advocates ignore a basic point of the law.

Expansion advocates often focus overly narrowly on issues they label as “patient autonomy” (even there the focus is on a narrow concept of what autonomy is, rarely acknowledging relational autonomy or other concepts beyond autonomy being what one individual is asking for at one point in time). However, they gloss over the simplest yet most crucial fallacy regarding potentially providing MAiD for mental illnesses. Our current MAiD framework is supposed to be for irremediable conditions. As I’ve written previously in Medical Post and elsewhere, and as CAMH has concluded, irremediability cannot be predicted for mental illnesses at this time. This is presented clearly following extensive evidence-based review in the recent Expert Advisory Group on MAiD report at www.eagmaid.org.

So, if patients with sole criterion mental illness receive MAiD, they are not getting it for a predictably irremediable condition, as they would be if they had ALS, cancer, or other medical conditions with known pathophysiology. They would be getting MAiD because society has agreed they had suffered enough, but they could get better. To me, it is discriminatory to expose those with mental illness to death based on assessors’ personal views and arbitrary opinions of irremediability, when the evidence tells us we cannot predict irremediability in mental illness.

Gaind then suggests that the new CPA euthanasia policy was developed in secrecy. He states:

...Many colleagues with senior positions in CPA leadership roles were unaware of any work CPA was continuing to do on this file (myself included, having completed my term and rotating off the board in September 2019). Despite having been chair of the sunset time-limited CPA task force on MAiD, and an expert on the CCA panel, CPA had not engaged me or any colleagues I know of with expertise in the area to assist with the file. Of more concern, since the 2016 CPA member survey done by the previous time-limited task force on MAiD, which showed only approximately 30% of Canadian psychiatrists supported MAiD for mental illness, there had been no subsequent engagement of general membership regarding their views as issues evolved.

Knowing that the six-month period after the Truchon ruling was coming up in March, and that federal government reviews were intended to start in summer 2020, I contacted the CPA CEO in mid-February to provide CPA with relevant informational updates, and to ask what the CPA was doing on this file given imminent policy changes. Other than a polite response from the CEO over a week later acknowledging receipt of my message, no information was forthcoming (other than confirmation that no-one representing CPA even phoned in on the national, open teleconference lines providing technical briefings on Bill C-7 on February 24).

Gaind continues on the new CPA position statement:

Imagine my surprise when, this past Friday, March 13, the CPA released a so-called Position Statement on Medical Assistance in Dying developed by the CPA Professional Standards and Practice (PSP) Committee. From a process point of view, this raised significant concerns, given the complete lack of member engagement on this issue preceding this statement. The PSP is a generic (i.e., not MAiD-specific) committee of several members (seven). It is unclear whether any additional expertise in the area of MAiD and mental illness was even sought through this process. If it was, it was certainly a well-kept secret from many of us who are CPA members.

Process aside, if such a Position Statement actually provided evidence-based guidance, it could still be of value. Unfortunately, not only does the PSP Position Statement fail to provide any evidence-based guidance regarding MAiD and mental illness, at this critical time when policies are being set, the Statement is actually, in my opinion, damaging and dangerous.

Dr Gaind explains his criticism of the CPA position statement:

The bulk of the one page (if you remove author affiliations) PSP Statement, consisting of five points, makes ‘apple pie’ comments referring to “having working knowledge of legislation,” being “mindful of the medical ethical principles as they relate to MAiD,” being “rigorous in conducting capacity assessments,” and providing information even if choosing to not be involved with provision of MAiD. It also makes a statement that “patients with a psychiatric illness should not be discriminated against solely on the basis of their disability, and should have available the same options regarding MAiD as available to all patients.” That’s it. No actual guidance on what any of that means. And quite remarkably for a Position Statement issued by a national expert professional medical association, after there have been years of focused review and study on the issue (for example, the CCA Panel Reports, and numerous and ongoing other national and international literature references), there is not a single reference to any citation regarding mental illness and MAiD, capacity or decision making, suffering, or above all, irremediability. Again remarkably for a psychiatric association, the three only citations are to Bill C-14 and the Carter and Truchon rulings.

Dr Gaind continues on why the new position is dangerous:

Had the PSP Position Statement simply been unhelpful, I would not have written this piece. Unfortunately, beyond being unhelpful, the Statement is dangerous. While the comment that patients with mental illness should not be discriminated against is self-evident, it is far from evident what CPA is actually saying with that comment. Does this mean that it would be discriminatory to not provide MAiD to patients with sole criterion mental illness? Or does this mean that it would be discriminatory to provide MAiD in such situations, since it would expose patients to arbitrary and unscientific determinations of irremediability that cannot be predicted? Again, remarkably for a psychiatric association, the PSP Position Statement never even once addresses or comments on the issue of predicting irremediability in mental illnesses.

Even worse than taking a position, the CPA has chosen to attempt to say nothing on this issue—and in doing so, in this politicized debate CPA has opened the door to dangerous and arbitrary interpretations of what this position statement actually means (perhaps fittingly, if they have also opened the door to expose patients to dangerous and arbitrary determinations of irremediability of mental illness that cannot be scientifically made).

Dr Gaind states that the CPA position on euthanasia for psychiatric reasons is embarrassing:

As a past president and current Distinguished Fellow of the CPA, it pains me to write this piece. I know how thoughtful, considered and hardworking all elected CPA Board members are. Many are my friends. However, my obligation to all our patients, and to what our members should expect of a member association, must outweigh these feelings. Through the process and content of this PSP Position Statement, by failing to engage or be respectful of its own members, by failing to even try to address any evidence-based recommendations and being silent on key issues needing guidance regarding mental illness and MAiD at this crucial time, the CPA has failed its members and our patients in its role as a national professional member association, and has in fact abrogated its role and lost any moral authority in this important issue.

Today, I am embarrassed to be a CPA member.

More information on this topic:

• Article: Canadian Psychiatric Association approves euthanasia (Link). 
• Article: Is euthanasia psychiatric treatment? (Link).
• Article: Why legalizing medical assistance in dying for people with mental illness is misguided (Link).
• Article: Canada's Justice Minister says that euthanasia may be extended to people with mental illness (Link). 
• Article: Quebec court expands euthanasia by striking the terminal illness requirement. Euthanasia for psychiatric reasons is next (Link).  
• Article: Psychiatrists must prevent suicide, not provide it (Link).
•  Article: Physically healthy depressed man died by euthanasia in BC (Link). 
• Article: Dr Mark Komrad: Why psychiatrists should oppose euthanasia (Link).
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