TORONTO — People’s wishes for end-of-life care are more likely to be honoured if they make clear plans for their deaths and share them, according to a panel of experts who recently addressed legal, medical and ethical questions associated with the final stages of life.
An information session with Rabbi Mordechai Torczyner, palliative care specialist Dr. Daphna Grossman and lawyer Brendan Donovan, was held Feb. 24 at North York Memorial Community Hall and attended by more than 100 people. Criminal lawyer Edward Prutschi moderated the town-hall-style meeting, which was sponsored by UJA Health Professionals, the Centre for Israel and Jewish Affairs and the Canadian Rabbinic Caucus.
In dealing with legal matters pertaining to end-of-life planning, Donovan, an estates and trusts litigator at Wagner Sidlofsky LLP, stressed the importance of a detailed written plan for one’s end of life wishes. He said writing something such as “no heroic measures” is an ambiguous instruction that could be open to interpretation, which is why detailed instructions are necessary.
Another legal matter is the determination of an individual’s competency in making a treatment decision and understanding the consequences. He said competency is of particular importance, given the recent Supreme Court ruling that struck down the ban on physician-assisted death.
Donovan recommended assigning a power of attorney for personal care, which he likened to a living will. A designated person becomes the substitute decision-maker (SDM), a trusted person who can follow through on an individual’s health-care or end-of-life wishes if he or she become mentally incapacitated.
Grossman, deputy head of palliative care at Baycrest Health Sciences, dispelled the misconception that palliative care hastens death.
Dying is a natural part of life, she said, explaining that palliative care helps a cancer patient “be more comfortable and less anxious” when no more treatment can be offered. “Palliative care helps the patient to live with dignity through the trajectory of the illness and to die with dignity.”
She said a study in the New England Journal of Medicine showed that palliative care does not hasten death.
Grossman noted that morphine, a drug common used in palliative care, alleviates shortness of breath, pain and anxiety.
Palliative care is also provided to people with non-terminal illnesses such as chronic lung and heart disease and amyotrophic lateral sclerosis (ALS), she said.
“There was a time when people died quickly and at young ages from these illnesses. Medical care and procedures has helped people live longer.”
Palliative care may be necessary for dementia patients in the last six months of their lives, when their level of consciousness decreases and they have increasing difficulty swallowing.
She said that people who ask to die are often socially isolated and/or have undiagnosed depression. “Some people rescind this request once their [psychological] needs are met.”
Grossman made the distinction between physician-assisted suicide (PAS) and what she called "active euthanasia." PAS is when a physician writes a prescription for a lethal drug that will be self-administered by the patient. The latter refers to a physician actually administering a drug that will cause death.
Rabbi Torczyner, rosh kollel of Toronto’s Yeshiva University Torah MiTzion Beit Midrash Zichron Dov, noted that there is a diversity of Jewish opinions on dealing with death, so he advised people to speak to their rabbis.
He said that in Judaism, there is a requirement to save life and to mitigate pain. He acknowledged that death from medication is an acceptable risk, if the goal is pain alleviation, but he made it clear that euthanasia, the administration of medication to deliberately end life, is a violation of Halachah.
The rabbi said people have the right to refuse treatment if the pain of a terminal illness can’t be abated or if there are low odds of success for a particular treatment. He also said it’s not necessary to prolong a life of pain caused by a terminal disease by treating a secondary condition such as a respiratory infection. “We don’t extend a life of pain.”
When it comes to end of life care, Rabbi Torczyner noted that there could be a “set of competing values” between what families want and what medical staff deem necessary. “Doctors are asked to represent the system. They are the guardians of resources in the health care system, which could be a conflict of interest.”
However, he added that families and patients who view physicians with suspicion must also appreciate the fact that physicians are in the business of providing health care. “Doctors do not go into this field to end life.”