EP. 47: ON MEDICALLY-ASSISTED DYING

Jan 31

WITH STEFANIE GREEN, MD

A physician who specializes in delivering medical assistance in dying explains why she chose this career and how she finds meaning through her patient relationships.

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Episode Summary

One of medicine's thorniest ethical questions concerns the lengths to which a physician should go to ameliorate suffering, including the use of medical means to hasten death. Yet, particularly for those who care for patients with, or for those who live with, serious illness, this question is all but inevitable. In this episode, Dr. Stefanie Green, the current president of the Canadian Association of Medical Assistance in Dying Assessors and Providers, shares her experiences helping patients die and how she views this branch of medicine. Dr. Green has been at the forefront of the change in legal regulation and clinical practice around medical assistance in dying (MAiD) in Canada. In her 2022 book, This is Assisted Dying, she shares the delicate, challenging, and humane moments she has witnessed while navigating this unique work.

Disclaimer: This episode does not advocate for or against medical assistance in dying. Rather, it seeks to understand why a clinician may choose to perform this work. If you are experiencing suicidal thoughts or a crisis, please call or text 988 to reach the Suicide & Crisis Lifeline, available 24 hours a day, 7 days a week.

After obtaining her medical degree at McGill University in 1993, Dr. Stefanie Green completed a residency in Family Medicine and then fellowships in Palliative Care and Infant and Maternal Health. She enjoyed a full-spectrum family medicine practice in downtown Toronto until 2001 when she moved to the USA for 10 months for her husband’s work. Her young family returned to Canada, relocating to Victoria, BC, and she quickly re-focused her practice on maternity and newborn care.
Dr. Green founded the Quintessence Maternity Group in 2002, the region’s first “hard-call” maternity service allowing practitioners to provide continual care throughout a woman’s entire labour and birth experience. She founded Gentle Touch Circumcision in 2012 to provide elective infant male circumcision for families across Vancouver Island.
After more than 20 years in practice, and in conjunction with a change in federal law, Dr. Green began working in medical assistance in dying (MAiD) in June 2016. She is co-founder and President of the Canadian Association of MAiD Assessors and Providers (CAMAP), medical advisor to the BC Ministry of Health MAiD oversight committee, moderator of CAMAP’s national online community of practice, and has hosted 3 national conferences on the topic. Dr. Green enjoys speaking about MAiD to the public, to health care communities, and to a wide range of audiences locally, nationally, and internationally. She is clinical faculty at the University of British Columbia and the University of Victoria.
In this episode, you will hear about:
• How Dr. Green transitioned from a career in maternity care to medical assistance in dying (MAiD) - 5:14
• A brief legal history of MAiD in Canada, beginning with Rodriguez v British Columbiaand including the sea change that came with Carter v. Canada - 6:39
• An overview of how MAiD works today in Canada - 12:14
• How MAiD works in the United States, specifically in California, and the role of prognosis in a patient’s eligibility for MAiD - 15:43
• Dr. Green’s reflections on how two decades working in maternity prepared her for MAiD - 20:45
• The specific process by which Dr. Green helps her patients die - 24:13
• The first patient encounter in which Dr. Green provided MAiD - 27:53
• Reflections on the frame of mind Dr. Green must adopt in order to perform this work - 35:04
• How Dr. Green processes the difficult emotions arising from her work - 43:22
• Dr. Green’s reflections on her role as a patient advocate when handling family conflicts at end of life - 47:50
• Advice for clinicians about connecting with patients through empathetic presence - 51:35
Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctors Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build health care institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across health care, from doctors and nurses to patients and health care executives. Those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine. We will hear stories that are by turns heartbreaking, amusing, inspiring, challenging and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Henry Bair: [00:01:03] Welcome to The Doctor's Art. The conversation we are going to be having today differs in some important ways from our past episodes, and Tyler and I wanted to introduce this episode with a special note.
Tyler Johnson: [00:01:16] One of medicine's thorniest questions concerns a physician's responsibility to those who are suffering. While we all agree broadly that doctors should ease suffering whenever possible, significant disagreement exists on the lengths to which a physician should go to ameliorate pain. For many years, an ethical consensus in Western medicine has held that as a patient approaches natural death, it is acceptable for a physician to administer medication necessary to mute pain, even if an inadvertent effect of muting pain is a side effect that may hasten the end of life. More recently, however, renewed debate has accelerated in the medical community regarding whether it might be ethical under certain circumstances for physicians to administer medications with the intent of hastening or even causing death. In California, for example, in 2015, the state approved legislation that allows for the prescription of purposefully lethal medications for that cause under carefully controlled circumstances. Canada, however, has gone much further; their Supreme Court decisions over the past many years, which we will explore in some detail in today's episode, have opened the door further than in almost any other country for physicians to aid patients experiencing unmitigated suffering and dying, even when death is not necessarily imminent. And this has resulted in a new subbranch of medicine, which is doctors who are devoted to facilitating this process as part of their declared specialty.
Tyler Johnson: [00:02:54] In this episode, we interview one of these physicians, and she shares with us stories that open to our audience a better understanding of why she does what she does and how she views this branch of medicine. This practice of physicians purposefully facilitating the death of a patient goes by various monikers. In the past, it was often referred to as "physician-assisted suicide." Now it is often referred to as either "physician-assisted dying" or "medical assistance in dying." Whatever name we use to refer to it, however, Henry and I want to recognize that our audience members will have a wide range of opinions about this practice, and some will likely be opposed to it on principle. Indeed, Henry and I differ in our opinions on this. Henry is supportive of the practice in many instances, whereas I, Dr. Johnson, am opposed to it on ethical grounds in almost all contexts. Having said that, the purpose of this interview is not really to adjudicate the ethics of medically-assisted dying, although we hope to do that with a different guest in a future episode, but instead to simply understand and explore the experience of Dr. Stefanie Green, the current president of the Canadian Association of Medical Assistance in Dying Assessors and Providers, who is today's guest.
Henry Bair: [00:04:20] Thank you for that note, Tyler. I'd like to add that regardless of how one feels about medical assistance in dying, it is simply true that many patients, especially those with serious illness, will at some point wonder about it and will want to discuss this option with their doctors. It is with an understanding that an exploration of this nuanced issue is inevitable in contemporary medical and ethical discourse that we welcome Dr. Green. She has been at the forefront of the change in legal regulation and clinical practice around medical assistance in dying in Canada and in her 2022 book, This is Assisted Dying, she shares the intricate, emotional and humane moments she has witnessed while navigating this unique work. Dr. Green, thank you very much for joining us.
Stefanie Green: [00:05:12] Thank you for having me.
Henry Bair: [00:05:14] Well, to start us off, can you briefly tell us what first drew you to a career in medicine?
Stefanie Green: [00:05:22] Sure, I haven't been asked that question in a while. I love it. Thank you. I think it is a little bit cliche. In truth, I love discovering how things work. And I think that while I was in school, even in high school, I kind of discovered the field of physiology. I find the human body wondrous. I think that I discovered that early and I remember specifically a particular class in high school and grade 12 biology when our teacher had to stand up and actually push all the chairs aside and we walked through and enacted meiosis and mitosis as if we were chromosomes. And I remember being fascinated with finding out how the body worked. And it quickly evolved into how people work and how they think, how they function, how they heal, how things can go wrong. And I thought if I could just understand how things worked and how they could go wrong, I could help to make them better or I could maybe learn to fix them. You know, the truth is, I didn't plan on a career in medicine, but I came to it as I followed my my interests in science and biology. It's really that simple.
Henry Bair: [00:06:25] Can you tell us more about your journey in medicine? I understand that before your work with dying patients, you had a previous career in maternity and newborn care. Can you walk us through that path?
Stefanie Green: [00:06:39] Sure. So I'm I'm trained as a family physician. I did family practice in Montreal at McGill University, and I was very drawn to two different fields. I was drawn to end of life and I was drawn to maternity care, both seemingly a little bit polarized. I did partial fellowships in both, to be honest, and I chose a career in maternity and newborn care, primarily with a big emphasis on that. I did ten years of general medicine with an emphasis on maternity, and then I did another 12 years exclusively in maternity and newborn care, which is a little bit odd, but I absolutely adored it. So I did that for over 20 years, and then I followed the legal changes coming in Canada when I saw our Supreme Court decision that changed the law about assisted dying. I became very interested in the topic. And it's not a straight path. It's not quite that straight. The issue of assisted dying was first raised in my mind for the very first time when I was in medical school doing a bioethics course and would have been a small sidebar, except that in our national headlines there was a very important case, a challenge in Canada unfolding the Sue Rodriguez case, and it was literally in the news every day. So we talked about that case and it was the first time I'd really come across the issue, and I'm sure that it's shaped my views.
Stefanie Green: [00:07:56] That case was lost. But over the next couple of decades in Canada, I watched as a Canadian reading the newspaper, other stories come forward and the debates that happened. And after 20 years of doing maternity care, I was getting a little bit tired physically doing 24 hour call shifts and recovering from that was becoming more challenging. And my children were growing up in about to leave the home and I had some pressure that I really wanted to be home before that happened. So none of this is a very straight line. But as I was considering pulling back and doing other things in medicine, this other opportunity was coming along in Canada. This event was happening and I was learning more about assisted dying with this lens of having practiced medicine for over 20 years. I had seen things that had made me more interested in what was evolving in end of life care in Canada. And the more I learned about it, the more I was drawn to it. So I actually made that that shift from transitioning into life and delivering babies to transition to the other end of life and and working in assisted dying. So not a clear path, but an interesting one, I think.
Tyler Johnson: [00:09:02] Can you just walk us through, many- well, we have listeners actually all over the world- but many of them do not live in Canada. Can you just talk us through maybe just a little bit of of that history that you were just referring to of of when did this become legal and what did the journey to legalization there look like? And then also, can you help us to understand what are the legal specifications right now? So in what context can it happen? How does it work? Just give us a little bit of a sort of the logistical framework as well.
Stefanie Green: [00:09:32] So I think it's important to understand that how we came to this in Canada is a little bit unique. The law didn't change in Canada because there was a voter preference for that or because the government of the day decided that it was a good idea and wanted to make a change. This change happened in Canada because patients stepped forward and fought what used to be a blanket prohibition of assisted dying in Canada, which is common in many countries still. And the challenge to that originally, as I mentioned, the Rodriguez case in the nineties was lost, but very, very close. And so what happened since the mid nineties was this this young woman who had a terrible illness, who had ALS or Lou Gehrig's disease, she challenged the prohibition, wanting to have an assisted death at the end of her life. She lost that decision 5 to 4 at our Supreme Court. But it really sparked a lot of debate in our country and really caught and captured the attention of Canadians who really felt for her, felt, felt her plight. And so we had discussions, debates, reports, more cases. And literally 20 years later, another family, a group of patients, actually came forward with a very, very similar challenge. And it's important because the argument they made was based on a constitutional document in Canada, and that's different than in other countries.
Stefanie Green: [00:10:50] So we have a Charter of Rights and Freedoms, which is a constitutional document in Canada. And the argument was that to have a blanket prohibition of assisted dying in every instance would infringe on certain patients rights in certain circumstances. And the decision that came out of that is known as the Carter decision. In 2015, it agreed that our Supreme Court actually unanimously agreed that that was the case and struck down the blanket prohibition of assisted dying and laid out some criteria and said in the circumstances that we have a capable and competent adult who has what they deemed a grievous and irremediable condition or a serious and incurable illness, essentially, and who was suffering intolerably in such a circumstance. It would infringe on their rights to not be able to act. And this is to death due to a blanket prohibition. And so with that, assisted dying was then allowed in Canada. The government responded to that High Court decision by regulating practice. Now they didn't need to do that, but it seemed important enough to our government to do so. So we have a national legislation which essentially makes an exception to the criminal code in our country. So it's no longer considered homicide if certain situations and criteria are present. That's really the framing of the legislation. And in in Canada, I should say.
Stefanie Green: [00:12:14] So it takes effect in the entire country and all our provinces and all our territories. That is true. But health care is administered provincially in Canada or territorially. And so we have a bit of a different rollout in each region. But essentially the law is the same everywhere. And so if you want an assisted death in Canada, you have to make a written request. You can't just ask for it verbally. It has to be the patient who asks. There can be no one else who puts them up for this, and nobody else can speak on their behalf. No patient representation, no powers of attorney. It must be the patient themselves. They need to make a written request. It needs to be signed and dated. There's a number of procedural safeguards around that request, and then they have to be assessed by two different and independent clinicians. And in Canada, that clinician could be either a medical practitioner or a nurse practitioner, which is fully recognized to be able to do this work within their scope of care. And the the criteria that need to be true today are essentially there's there's essentially six things a patient needs to be over 18 years of age. They need to be an adult. They need to be eligible for Canadian government funded health care.
Stefanie Green: [00:13:24] So anyone in Canada who's eligible for universal health care qualifies. They could be citizens, they could be landed immigrants, they could be refugees with status. It's really meant so that no one can come from another country and pay privately. So that's not allowed in Canada. The patient needs to make a voluntary request. It needs to be clear that they're not coerced in any way. Not not explicitly, not subtly. It's the patient themselves that lines with their values and they can explain why they want this care. It's my job to make sure they're not coerced. Patient needs to have capacity to make this request. They need to you know, I could talk to you for a long time about what capacity means, but essentially, you know, to have the capacity to make this request means that they have an understanding of what's wrong. They have an understanding of what their treatment options are, and specifically including palliative care in our law, that they understand the pros and cons of those treatment options, that they can articulate questions and about those treatment options that they can appreciate what would happen if they had an assisted death, that they would die, that that's irreversible. They can appreciate what would happen if they don't have an assisted death, what their life would look like, and they can articulate a request and communicate that.
Stefanie Green: [00:14:35] And then with all of that information, they can give an informed consent. So all the capacity and informed consent are an essential element and it's rigorous. And then the final thing that needs to be true is that the patient needs to have what we still call a grievous and irremediable condition, the definition of which is broken down in our criminal code and says that the patient must have what we call a serious and incurable illness, disease or disability, that they are in what we call an advanced state of decline and capability, essentially, meaning they're no longer functioning in the way that they used to before their serious illness, disease or disability, and not in just some small way, but in an advanced way, and that they're suffering in a way that they themselves deem intolerable. And that cannot be relieved by any means acceptable to the patient. So all of those things need to be true in order for a patient to be eligible for an assisted death in Canada. It's quite rigorous. And on top of that, there's a number of procedural safeguards which I won't go through. Them all know things like the written request is signed and dated and witnessed, and there's there's a number of other procedural safeguards on top of the eligibility criteria. It's a very rigorous system.
Tyler Johnson: [00:15:43] So one thing that is striking to me, as I think all of our listeners know, Henry and I are based in California, we're both at Stanford and California also has a law and has had for about six years, which allows for physician assistance in dying under certain circumstances, obviously. Well, nobody on this podcast is a legal scholar, right? So we're not going to be familiar with all of the different specifications all over the world. But one thing that is very interesting to me, just comparing it to the statute that we have here in California, just for a very brief background, the way that the statute in California for our listeners, I'm sure you already know this, but for listeners, the way that the statute in California works is that if there is a patient who's interested in physician assistance and dying, they can go to their doctor and request that they be enrolled in the program if they want to enroll in the program. Just like in Canada, there have to be two different physicians who sign off. One of them is there for verification purpose. Says one of them is there for prescription purposes. The verification physician has to say that they believe that it's reasonable to assume that the patient has a prognosis of less than six months.
Tyler Johnson: [00:16:47] And then the the doctor who is doing the prescribing has to also sign off on that prognosis. And then they actually write the lethal prescription. And then the prescription is filled for the patient and then the patient takes it home and can take it or not take it as they see fit. So all of that is to say that one thing that is striking to me, if I'm understanding correctly, the the Canadian statute that is quite different from the Californian statute is the fact that in California the weight of being able to participate is on this assessment that the physicians do, that the person has a prognosis of less than six months. But it sounds like in Canada there's no line in the sand in terms of specific prognosis or in terms of even really anything specific, except that it has to be a condition that is, as you said, very serious, causing a lot of suffering and and that the patient wants to predict in the program. And then there are a lot of things about making sure that the patient has capacity and whatnot. But do I understand that correctly?
Stefanie Green: [00:17:48] I mean, essentially, yes, There is no requirement in Canadian law for the patient to be terminally ill or have a particular prognosis. That is correct. Our original High Court decision, the Carter decision in 2015, it's a 395 page decision by a constitutional expert. And in that decision there was no requirement for a particular link to end of life that patients who are suffering intolerably, who have capacity to understand what the requesting and all the other eligibility criteria I talked about are able to proceed, that the element of intolerable suffering is the key element, and it's not about particular prognosis.
Tyler Johnson: [00:18:27] That's correct. And and the intolerable suffering, though it has to be signed off on by physicians. It sounds like it's largely sort of what that means or this is a funny way of saying it, but what quote unquote counts, it sounds like, is that's mostly left up to the determination of the patient. Is that right?
Stefanie Green: [00:18:46] So it is a subjective criteria in Canada. So it is up to the patient to determine whether they are suffering or not. And I think that makes sense. I mean, to some extent people often talk about that and flag it. But I think one of the interesting things in my book, I talk about the difference between pain and suffering, and I talk about that because if I if I come over there and pinch you and Henry both, you might have very different reactions. You might have the same experience of pain. I pinch you with my finger on your forearm, both of you, and you'll both have the same amount of pain. But, Tyler, you might. You might think, Well, that was weird. I don't know why she did that and then go on with your day. And Henry might think, Oh my goodness, I don't know why she did that. She's going to come back and do it again. She's going to use an instrument next time and and maybe draw blood. And he's going to suffer more than maybe someone else. And so suffering. I say that because suffering is a very personal experience. Right? Suffering is based on our own experiences in life, our own traumas, our own experiences, our own brushes with other people and and events and suffering is not really for me as a clinician.
Stefanie Green: [00:19:50] I can't say whether you are suffering. I think I need you to explain to me what's happening to you, and it's certainly not up to me to decide how much of that suffering you can endure before you deem it intolerable. Right? That's not for me to say. I've had patients with the same diagnosis in the same decade of life at the same stage of their illness. You know, these can be terminal cancer patients. And one of them will say, I, this is enough. I'm done. I can't do this anymore. Please come and help me next week. And the other patient would say, I'm really done. I really can't do this anymore. I'd like to proceed. But I have a grandbaby being born in three weeks. I'd like to hold that baby once and then I'm ready to go. So what someone can endure again, like suffering. The nature of suffering is a very personal determination, and I think that's what the Canadian law is recognizing and allowing the subjective nature of it, allowing the patient to determine when they're suffering and how much they can tolerate.
Tyler Johnson: [00:20:45] Well, so you already alluded to this a little bit, but it is I think anybody would recognize it as genuinely striking that in your medical career, you you move almost immediately from an emphasis on welcoming humans into the world to an emphasis on helping humans to exit the world on their own terms. And so talk to us both a little bit about you did this a little bit already, but talk to us a little bit about what drew you to that shift and then what's that been like? I guess how do those different parts of your medical career compare with each other?
Stefanie Green: [00:21:23] Yeah, I have been quite struck. I mean, there's a lot of paradox in the work that I do. I did not expect quite as much of that. And one great example is my shift actually from maternity to to assisted dying. I find I found when I when I did my work in maternity care, as I'm sure many of your listeners who are involved in that kind of work will recognize, there's a certain art to the work of working in maternity, like many fields of medicine. You know, I enjoyed preparing people for things, being a knowledgeable guide. But when I walk into the room to help someone with labor and delivery, I am acutely there aware that I am there to help guide them through one of the most intense days and one of the most important days in their life. There's a lot of emotion. There's a lot of family dynamics at play, whether the mother in law will be around in the room or not. There's a lot of intensity. There's a lot of unknown. We have kind of a known ending we're trying to get to. But how we're going to get there is a little unknown. Will she deliver in the car? Where she deliver in the delivery room? Will she need a surgery? What could go wrong? So there's a lot going on. Pretty intense. And I'm also acutely aware in that moment that I am not the most important person in the room, the mother and the baby. And that dyad are most important. And at some point, I hopefully have the privilege of helping Mom place that wet and screaming baby onto her chest for the very first time.
Stefanie Green: [00:22:49] And then there's a big celebration. And it's not for me to stick around and sip champagne with the family. That's when I respectfully withdraw from the situation that I've been very intensely involved with and allow that family, that moment to celebrate this new life. And there's a real beauty in that and and a real art in choreographing my role and that whole event. And I was passionate about my career. And everything I just said about maternity can pretty much be said about an assisted death as well. In Canada, clinicians are primarily involved. We administer the medications. And so again, I am present at this very intimate scene, very emotional, very intense, one of the most important days in someone's life. A lot of family dynamics. I am there as a knowledgeable guide and at some point when I pronounce death, it's not for me to stay and grieve with the family. I will stay and help them for next stages, but I will remove myself respectfully from the moment and allow that family, that moment of grief and bereavement. And so I found my skill set incredibly transferable from one to the other. I actually find the skill set very, very similar, and I find the work in that sense very, very similar. I feel very lucky to have spent two decades in maternity care in order to prepare me for end of life work. It's it's not something I expected, but I found early on, and I'm constantly amazed at how that remains true.
Tyler Johnson: [00:24:13] Your description there reminded me that I neglected to ask you one of the most fundamental questions, which is so again, in California, when this happens, the role of the physician is literally to write a prescription which is then filled at a pharmacy, and then patients have it there in their medicine cabinet or whatever. And actually, we have pretty good data from California that many patients never even take the medicines. But from what you were just describing, I gather that in Canada it's a much more active process. Can you talk us a little bit like what do you actually do on on the day that this happens?
Stefanie Green: [00:24:46] Yeah. So in Canada, we have both options available. I mean, around the world, people use different terminology for different things. Old school terminology would suggest an assisted suicide is when a physician or clinician writes a prescription and the family like in California, would pick it up and have it in the home, have some safety concerns with that. But but know it's up to them to self administer the medication. The other option is what those in Europe would call euthanasia, where the clinician actually administers the medication themselves. You know, usually intravenously in Canada recognized both of those options. And we we call them self administration and clinician administered assisted dying. And our umbrella term is medical assistance in dying that incorporates an either of those options. So both are allowed. And what we find in Canada and in any jurisdiction in the world where clinicians are allowed, permitted by law to administer medications, the patients overwhelmingly prefer and choose that. So in the Netherlands, it's over 95% are clinician administered. In Canada, it's 99.9% of events are clinician administered. So on the day of the event itself, after I've been through an entire process with the patient and we've prepared and been through the rigorous process, they've been deemed eligible. They've eventually set a date when we get to the time and the place of the death itself. It's my responsibility to have written the prescription. It's my responsibility to pick it up from the pharmacy. I sign for it, I'm responsible for it. I take it to the place where this is going to happen. Typically, where I work, it's in someone's home. I arrive. I mean, there's many things that happen. I have a private conversation with the patient at that point to ensure that they haven't changed their mind.
Stefanie Green: [00:26:21] This is truly what they want. They know they can change their mind, make sure they still have capacity to to give consent. And if they do and they still want to go ahead, then we start preparing. My nurse will come and start an IV. I will prepare the family or any gathered guests for what is to come. I outline what's going. Happen, the order of events, what they might witness. I answered their questions. We eventually gathered together. We accommodate any ritual or ceremony that the patient has has requested. That could be a party of 50 people drinking champagne and telling stories. Or it might be a very small event with two or three people with prayer and everything in between. There's there's quite a variety of what I've seen. And and I'm constantly amazed at the unique nature of these events, often reflective of the patient and the way they've lived their lives. It's quite fascinating and and beautiful in some way. And then at some point, I will begin the procedure. We administer a protocol of four medications I give them in no particular hurry. They are done through IV push. The event typically takes the medical event, the actual administer of medications from beginning of the first injection to the end of heartbeat. Roughly, if you look at our data somewhere between eight and 10 minutes, I will stay with the family, make sure that they're okay afterwards, debrief with them, make sure they have resources, help them through the next few steps. So so I have a role in all of those parts in this work, from prescribing to attending to administering to to helping the next steps.
Henry Bair: [00:27:53] Thank you very much for walking us through that, Dr. Green. So your book opens actually with with you recounting the first patient you helped in this line of work. And I think it's it was a very vivid portrayal from both your perspective of what that was like and from the patient's perspective. Can you share with us for our listeners what that experience was like?
Stefanie Green: [00:28:20] Yeah. Unforgettable is the first word that comes to mind. It was my first experience, and of course, it would be seared in my mind, I think, because of that. Anyways, I feel quite fortunate to have worked with that family in the beginning. They were extraordinary in ways because this was new to everybody, new to me, new to them, new to Canada, and they were incredibly supportive of their loved one. I actually if you don't mind, I'd like to tell a little bit about that story. I mean, maybe that's what you're asking me.
Henry Bair: [00:28:47] Yes, please do.
Stefanie Green: [00:28:48] It's a person I call Harvey in the book. And Harvey was one of these people that had kind of lived the dream or emigrated to our country as a young teen, worked hard, two jobs to get by, eventually founded his own business, started a family, gave back to the community like a real, you know, that kind of guy. And by the time I met him, unfortunately, he was in his mid seventies. He was dying of end stage liver failure. He was quite ill by the time I met him. And and Harvey had been watching the news. He had been following the story, hoping, literally hoping to live long enough so that he could take advantage of this new option at end of life. He knew what he wanted and he was, as I like to say, metaphorically, knocking on my door the day the legislation passed. And so a very determined guy and with a lot of support of his family. I saw him, I assessed him. I got to know him and his wife and and in fairly quick order, because he was so sick, we were able to tell him he was eligible. And I would point out that he was the first time that I saw something remarkable that I see in every patient. When I sat in front of Harvey and told him he was eligible for this care, it was like this transformation happened. He smiled. He relaxed.
Stefanie Green: [00:29:58] I saw his shoulders drop. I saw his head nod. I saw him smirk a little, and he expressed his gratitude to me for this possibility, for for the mere possibility that this could happen. He stopped focusing on how he was going to die and what that might look like and what his fears were about that. And he started planning how he was going to live. The last couple of days and weeks of his life. He organized a going away party, you know, an open house at his home for his friends and neighbors and coworkers. And they would come by and they would say goodbye and kind of toast him and roast him and tell stories. And he did that one weekend and really got to find a lot of closure. But on the day of his actual death, I arrived and his quite a lot of family there. I went through all the steps I just talked to you about. I spoke with him. I spoke with his family. And in fact, if you don't mind, Henry, I'd like to maybe just read you a couple of paragraphs. Would that be okay to explain what what that really looked like?
Henry Bair: [00:30:54] Mm hmm. Yes.
Stefanie Green: [00:30:55] So now that you know a little bit about who Harvey is and that I had spoken to him, I'd spoken to his family, this is what happened. So I walked into his room and it was just myself and his family in the room is a small bedroom:.
Stefanie Green: [00:31:09] Harvey is calm, he is smiling and he appears certain his love for family has been evident from the start, and they are all here with him now. Norma is sitting on a chair, tucked in tightly on his right side, leaning in her face close to his. She is smiling and crying at the same time. Harvey's children are reaching out to touch him, his feet, his legs, his hands. We are all huddled in closely around his bed. All faces towards Harvey. Everyone present just as he asked. The support they give him in these final moments, putting his needs above their own. It feels very brave to me and very loving. I ask if anyone has anything left unsaid. Harvey's son reaches out from beside me and places his open palm directly onto Harvey's chest. He repeats that he loves Harvey and thanks him for being such a great dad. Harvey reminds them all that this is what he wants and asks them not to be sad. I take hold of Harvey's left arm only after he looks me in the eye and thanks me one last time do I think to begin. "But maybe now is a good time to think of a great memory," I begin, "when you were doing something you loved, maybe with someone you love doing it with. Go to that place now. Be there and feel that moment again. If you feel sleepy, go ahead and close your eyes. You've earned it. We're all here with you now. We're going to stay here with you." Then Harvey dies exactly as he wished. Being held by his children and gazing into the eyes of his wife as he begins to feel sleepy. His wife of 52 years. They connect here, forehead to forehead, whispering to each other as I continue. She holds his face in her hands, strokes his head, and tells him it's okay. She tells him she loves him, that she will miss him, but that she is all right. She whispers inaudible words, evoking private memories, and he smiles. The intimacy of this moment is so absorbing that I struggle to focus on what I'm doing. She tells him to let go, that she is here with him, and as on most nights of his life, hers are the last words he hears as he falls asleep. Harvey musters a light snore. Norma recognizes the sound and dabs at her moist eyes. I continue with my protocol, and Harvey soon stops breathing. No one says anything when it becomes apparent, but I'm certain we all take notice. I understand in that moment that I'm witnessing this event as much as I'm orchestrating it. I feel a certain relief with events unfolding as I expected, but I remain vigilant for complications and alert to the unknown. I continue on to the final medication and immediately notice it doesn't flow as smoothly as the others did.
Stefanie Green: [00:33:42] I have an instant of panic wondering if my IV line has become blocked, but it takes only a moment for me to understand it's because his blood is no longer circulating. I am certain Harvey's heart has stopped, but I continue nonetheless. Only after the last medication is delivered do I cap and lock the IV. Only after the empty syringes are resealed within the plastic container do I reach for my stethoscope. And only after I listen for a complete 60 seconds do I announce he's gone. Only then do his family members allow themselves to be overcome by the loss they've all been suffering. There are vocal sobs, tight clenched hugs and flowing tears. This man will be sorely missed. To my utter astonishment, there's also an immediate outpouring of gratitude for what I have just done. And for this, I'll admit I was unprepared.
Stefanie Green: [00:34:31] You know, it's hard to explain what I do sometimes, but I think that when people ask me, what's it like? What do I do? What exactly happens? I think the the honest answer is I help people. I am incredibly privileged to be invited in to a time in someone's life where they're saying goodbye and they're doing the work of dying, and I'm asked to help facilitate their final wish. I find it incredibly privileged work, and that's that's a taste of what it's like.
Tyler Johnson: [00:35:04] You know, that's that's a really moving and beautiful story. We we've spoken on the podcast to many, many, but a number of palliative care doctors or intensivists as well. People who take care of a lot of people who are dying. And one of the themes that has shone through those discussions, which I think is I can hear echoes of this in the way that you tell the story and in the way that you talk about the paradox of that your skill set from delivering babies, many of those things also applying in the work that you do now is this idea that perhaps the two most sacred or whatever similar word you want to use moments in medicine are the beginning of a life and the end of a life, so that you know that being there when someone dies, it does have a whatever you want to call it, a metaphysical resonance to when a baby enters the world. And I, I guess I. I wonder. Do you find that that that sense -I don't want to put words in your mouth, so if if sacred is the wrong word, please substitute whatever you think the right one is- but that sense of something special, does that apply every time that you go to do this work? Or are there times when you go to do it and and you find yourself torn about what's happening or your, I don't know, somehow unsure or it's less, I don't know, less intuitive than than what you've described so far. I don't know if that question makes sense.
Stefanie Green: [00:36:57] No, no, I think I understand the question. I think and it's an important one. I, I like to think I'm not unique in when I did the work of maternity care. I like to think the great majority of my colleagues who do that work not only love their work, but recognize the privileged position they're in to be there to help with that incredible moment. I think I never took it for granted, and I think there's a recognition of the yeah, I don't use the word that use the word sacredness, but the unique and special moment that we're invited into with this family, that very special time, you could say sacred time. And I think at the end of life, there is a recognition that this is happening. I mean, because I'm there, it's happening in front of me, right? I I'm speaking with this person. And then, you know, ten, 15 minutes later, they're gone. So I'm very aware of that transition and my role in it and witnessing it and seeing it unfold. It never it's never routine. No two births are ever the same. I know that we all think that the end product is the same, but no two births ever go the same way. I've seen thousands. I've been involved in many. They're different because the people are different, the dynamics are different, the circumstances are always unique and a death is the same way.
Stefanie Green: [00:38:17] And so. I am constantly surprised seeing new things in awe of how people support their loved ones, the things that are said, the things that are not said. The way that people handle themselves. There is the same feeling of that sacredness, for lack of a better word, of that moment. Like most clinicians that do this work, I'm acutely aware of what happens if I get my work wrong, if I don't do it well, if I don't follow the law, if I break the rules anywhere, there's criminal liability sitting in the back of my head, blaring out loud and neon signs 14 years in jail or 14 years in jail. So I don't know anyone who does this work, anything less than cautiously, carefully and conscientiously. So I have never proceeded with a patient or a family where I have felt not at ease with the process and the outcome of it and my decision of eligibility. Because if I ever felt that I wasn't sure or it really wasn't right or something was very too much on the on the line, I wouldn't proceed. I'm not an activist. I'm not out there to prove a point. I'm there to facilitate a person's final wishes.
Stefanie Green: [00:39:30] So I need to follow the law. I need to follow my professional ethics. I need to follow my own personal moral compass. And if there's a case or a situation I'm not comfortable with, I will withdraw and transfer to a colleague. So I sleep quite well at night. I know the work I do is careful. I feel comfortable with the outcomes. I feel very comfortable with my role in it. Very comfortable may be the wrong expression. I'm very aware of that special nature that I've been invited into. And I'm I am not torn. I would be it would be naive for me to say I'm not often devastated by what I see some you know, somebody's life is ending. Right. Let's not pussyfoot around this. Somebody's life is ending. It's always sad. It's it's it's always sad. There are cases that are tragic. I've helped people that are young, that have young children that are in circumstances I wouldn't wish upon an enemy. These people are suffering intolerably by definition, and they've come to me to ask something that's almost unimaginable. So I'm aware of that. I'm affected by that. I see that. But I don't feel bad about my role or what I do. I feel like I'm helping people, so I carry both of those things.
Tyler Johnson: [00:40:41] One quick clarification. Does the law extend to people whose medical suffering arises uniquely from psychiatric causes?
Stefanie Green: [00:40:51] So it's an interesting question right now in Canada. So the original High Court decision, which I talked to you about, had these criteria about being adults with grievous and irremediable conditions that were suffering. There was specifically no link to end of life, and there was specifically no exclusion of any particular type of patient based on diagnosis. Right. So it didn't say if you have dementia, you can't have this, or if you've got a psychiatric illness, you can't have this. It didn't it did not exclude anybody because it's based on rights. The original government legislation, however, was more restrictive and did put in some initial attempt to link this to end of life, but still did not restrict any particular patient population from accessing made. It's just that you had to meet all the criteria. So for example, someone whose sole underlying condition was psychiatric or was a mental health disorder probably couldn't have made it through the eligibility criteria originally because there was originally requirement that a patient needed to have what was called a natural death. That was reasonably foreseeable. That didn't mean terminal, but it meant on a trajectory towards end of life either temporally. So at sometime soon ish without a time frame being around that, or predictably so, like an analyst patient might have 3 to 5 years to live, but predictably so they would have a reasonably foreseeable natural death.
Stefanie Green: [00:42:12] That requirement was lifted out of our law in 2021 as unconstitutional wasn't meant. It wasn't put into the original decision. And when the government tried to add it, it necessarily needed to be removed. And when it did, it left open the door for patients who have mental health disorders as their sole underlying condition to access made along with others. And the government was fearful of that. And so in 2021, for the very first time, our law specifically excluded patients based on diagnosis and said if mental health is your sole underlying condition and that's why you're applying for made, you may not access made that would not qualify as a serious and incurable illness, disease or disability for the purposes of this law until March of 2023, when that exclusion will automatically sunset out of our legislation, giving our government two years to to look at this issue specifically and see if extra safeguards were needed or how we might approach this potentially vulnerable patient population. So not an easy answer to your question. Originally not excluded, currently excluded. About to be not excluded in March of 2023.
Tyler Johnson: [00:43:19] Thanks so much for that explanation. I really appreciate that.
Henry Bair: [00:43:22] So you previously mentioned how some of these circumstances you witness in this line of work can be very devastating. Can you tell us more about how you grapple with those emotionally challenging situations?
Stefanie Green: [00:43:36] Yeah, I appreciate the question. And we certainly have spoken to colleagues. You know, I've spoken with colleagues in other jurisdictions who had given some advice about, you know, taking time and making sure that I had found balance in my work and a lot of caution about how much to do this or how little to do this. In the beginning, I was a little bit more nervous about how I would perceive my work and how I would absorb it. But I have found it's difficult to say, You know, the optics aren't great, but I have found I don't feel burdened by the work, despite it being intense and emotional and sometimes devastatingly sad. Because because more so than that. I have really found the work to be profoundly meaningful work. I have a group of colleagues I have co-founded and now the president for a group called the Canadian Association of Made Assessors and Providers by a grassroots, collegial group of professionals that came together to support the people that do this work, realizing we needed that kind of support because we come from different backgrounds. We're predominantly family doctors. We have internists, OBGYNs, neurologists, psychiatrists, internists. So there was no group or association that would really represent us in our work or our needs. We created this group, and I say that because it's been a cornerstone of my support. I feel very supported in my work by the few colleagues that do this work. We learn together, we grow together, we share our experiences together.
Stefanie Green: [00:45:03] You know, we can talk freely about what really happens in that room and how we cope with it, how we deal with angry families or difficult situations. I feel very supported. And so that's been a cornerstone of how I cope with this work, because I have professional support, because I have collegial support. I feel supported in the work. Personally, though, I have heard my colleagues say that this work has has reminded them of why they went into medicine. And I know that sounds a little. Crazy, perhaps for some of your listeners, but there's a lot of problems in how the medical systems work these days, and there's a lot of frustrations, a lot of doctors that are not happy about what they can and can't do and the limitations they have in medicine and. I know that sounds odd, but doing this work and being so patient focused and being so patient centered and being eligible to to step into this space with patients, to really hear them, to hear what's important to them, to hear what they need to be able to offer that to them, to facilitate that closure, for them to bring their families together, to facilitate those conversations, to allow them options, even if they don't follow through, to say to a patient, you are eligible for this care, and now it's in your hands to empower them. That way is therapeutic for the patient in and of itself. And we see that when I when I make that statement to Harv in my patients, like 80% of my work is done.
Stefanie Green: [00:46:31] Even if patients don't go on to have an assisted death, they feel better. They feel listened to. They feel validated. They feel heard. They feel empowered. And now it's up to them. And if I go through and help them with that, it's because I'm following their wishes. I it's not that I feel good about what I'm doing. It's like I feel good that I've done something good. I've facilitated this person's last wish. I have done something good for the patient, and that makes me feel like I'm helping them. And I think if we all go back to why we went to medical school, no matter what we said in our interviews, that's what physicians do, right? I'm a family physician. People come to me at very vulnerable times in their lives. They come to me as babies, adolescents, middle adulthood, life crisis, end of life, geriatrics, extreme illness. They come to me when they're vulnerable. And I, as that expression goes, I you cure sometimes you care often. And my role is to comfort always. I think clinicians help people. That is the essence of what clinicians do. And I feel in doing this work, I am helping someone. So I feel good about my work. I feel I've done something good. I don't feel devastated by the work. I feel devastated by certain people's circumstances, but I'm very comfortable in my role in it and I feel supported professionally in it.
Henry Bair: [00:47:50] That's that's that's really great to hear. You know, earlier when you were talking when you were sharing the story of Harvey, I couldn't help but think that, you know, all patients would be so lucky to have the level of family support around them in moments of suffering and serious illness. You've also just said that you do deal with circumstances when there are conflicts with the family. I'm wondering, how do you how do you deal with those circumstances?
Stefanie Green: [00:48:16] Yeah, I find that very challenging. I mean, it's always my goal for patients and families to be together on this plan. It is very challenging when that's not the case. And I've certainly seen that. You know, there's a lot of opponents to made who are concerned that patients will be coerced into this work. I've almost never seen that, to be honest. And six years I can think of one case where I was concerned about that and did not allow a patient to go through. I have seen many, many more times when patients have been coerced out of following through with an assisted death due to their family's wishes. And I find that, you know, that's their choice. I find that a little bit sad for the patient. But that's okay if they're willing to to follow that path, that's fine. I've certainly seen cases, I'm happy to say few, but there are certainly circumstances where patients and their families do not get along at all. And there's there's heightened emotions and sometimes even very, very negative situations where there's yelling and screaming. I see it as my role to help advocate for my patient. I try to bring patients and those who disagree with them together in a respectful, safe environment where they can express their opinions to each other.
Stefanie Green: [00:49:23] I find in a great many circumstances they've not hurt each other, not in any sort of safe and respectful way. I encourage patients to speak on their own behalf, in their own words, to explain what they're asking for and why. And sometimes it's the first time a loved one will hear the truth from a patient about what they're going through. And that can be very powerful. And in the same way, I ask patients to listen to what their loved ones are saying, what their fears are, what they're worried about, how they feel guilty or burdened or angry or and why. And so I find if I can facilitate that conversation, 80% of my work is done. And frankly, I think that's something we should see in discourse in our world today, that we're sorely lacking in education and politics in a lot of different forums. So that's my first goal. If I can't achieve that, or if I can't personally facilitate it because I don't have the skills to because it's too difficult, I'll bring in counselors or professional counselors to to try to facilitate that. And if that's still not possible, then sometimes I need to speak to the parties separately. Ultimately, we can't always bring people to the same table.
Stefanie Green: [00:50:27] I do find the vast majority of times support people. Loved ones will rally around to some way of respecting a person's decision, but not always. And in the end, the law is very clear in Canada that this is patient centered, patient driven care, that the patient's wishes are to be respected. There is no legal requirement for us to include family in decisions around assisted dying or at the end of life event itself. And if patients actually instruct me not to tell their families explicitly, I can't, That's a professional practice guidance. My my licensing body would have a problem with it if I broke that patient directive, so to speak. And legally, we know that the courts have said in Canada that patients families are not able to legally interfere with their access to assisted dying or to use the courts to delay that action. So the law is clear. I know that I have to take my my orders from the patient, but I do try very hard to incorporate family and loved ones in this decision because I know it makes for very complicated grief. If we can't bring people to at least hear each other out. So challenging for sure.
Tyler Johnson: [00:51:35] So, Dr. Green, you've been so generous with your time and we want to make sure that we we respect the amount of time that we said we were going to take. I think back to the point that you were making a minute ago. So the central thesis of this entire podcast is the idea that we have been struck that there are I have to say, I don't know the data in Canada, but at least in the United States, there is replete evidence now that many, if not most medical practitioners have lost touch with what makes their work meaningful. And to be clear, there are many, many explanations for the causes of this many, or most of which lie beyond the reach of any individual physician. Right? It has to do with corporatization of medicine and the bureaucratization of medicine, and EMR demands in any way a whole bunch of other things. But we still believe that there is some central zone of autonomy where there is at least something that physicians can do to help their work to be at least more meaningful. And so I guess obviously you're engaged in a in a particular branch of medicine that is unusual, but. Still speaking to sort of universal themes, I guess, and especially speaking to people who are maybe medical students, medical trainees, early career physicians, what have you. What advice can you give people for what they can do to if they feel like they have lost touch with what makes medicine most meaningful, to get back in touch with, with that that ethical imperative that brought them to the practice in the first place?
Stefanie Green: [00:53:18] Great question. You know, whatever field of medicine you're practicing, in the likelihood that you'll find more meaning in your work and day to day is going to be, you know, pivoting away from all the things that we have to do, all the things that you mentioned, the EMR or the billing, the complicated things, but really spending just a fraction of extra time. As they say, laying hands on. I feel like I'm speaking to a medical student. I don't mean to be paternalistic. I think the key to finding meaning in our work is to focus on the patient, listen to our patients. We do that, we do that, but we get distracted from it, right? We get distracted because of all the demands on us, all for good reason. And and that all still needs to be done. But taking an extra few minutes to focus and hear and listen to patients that patient centered care, that principle of practicing patient centered care for me anyways, brings the most meaning to my work. That's where I realize I am interacting and touching another person's life. That's where I feel I have the most impact on the possibility of helping someone. If I have connected with them and listen to them, then they are more likely to listen to me. And when if I have a suggestion about a treatment or a suggestion about care, they're more likely to hear me. If I've given them the same respect of listening to them. The laying on of hands. Medicine has moved to tests and investigations, but that connection with patients, that patient centered ness of our work, I think, is the core of where we can find meaning in our work and bring us back to that, that I happened to do it in, as you say, an odd way, I mean, in an odd field of medicine, sure. But you can imagine that's what brings the most meaning to me. I have a lot of that in this work, so it feeds me in that way. I think that's the essence of it.
Tyler Johnson: [00:55:15] And to your point, and again, I mean, I acknowledge what you said about I mean, I know you don't want to sound paternalistic or whatever, but many people who listen to this podcast probably are trainees or medical students. And so I think some teaching is appropriate and important, which is just to say that I think in the description that you give of your experience with Harvey, the thing that strikes me the most about your description is how wholly present you clearly were to the moment, right? That it was not a this was not like a functional or logistical thing that you were checking off of your list. Right? It was it was clearly you as one human who, because of your training and licensure and knowledge and everything else, has been allowed access to this very. Unusual ability to administer these medications. But anyway, it was you, this one human. There was this other human who was connecting with a room full of people who were near and dear to him, even though afterwards you gave them space and whatever as you describe. But nonetheless, in the moment, it's clear that you are fully present there. And I think that that which is what you're alluding to, I think right now. Right. That sense of being fully present, you can't be fully present within you can be fully present with a person.
Stefanie Green: [00:56:42] Exactly. And and there was a powerful example of that recently was with another patient. I was I was doing a television documentary about a patient who was another remarkable man. And he very, very courageously allowed cameramen into his assisted death, which I hadn't recommended. But anyways, they did. And he was lying on the bed with his wife and it was quite emotional. And the cameraman came to me afterwards and said, Did you notice what he did? And I, I hadn't. I was focused on what I was doing. I had connected with him, but I hadn't really noticed this. He said he looked at you and he he thanked you. And then he turned to his wife and said he loved her and he was about to fall asleep. And his last words actually, he turned back to me and he said, "Thank you, Stefanie." And then he fell asleep. And I, I didn't really I hadn't noticed that. And the cameraman said to him, it was so important that he had this option that that he had he wanted to thank you. That was the most important thing for him in that moment. And I say that not to to sound arrogant. I think it's important that that connection with patients, this mere possibility for patients is so, so important when we listen to them. But what's most important to them, they express that it's it's very, very moving and it's very, very meaningful.
Henry Bair: [00:58:00] Well, With that, we want to thank you, Dr. Green, for sharing with us your stories of a side of medicine that we don't often hear about.
Tyler Johnson: [00:58:10] Thank you so much for being here with us. We really appreciate your time.
Stefanie Green: [00:58:14] I appreciate the opportunity to speak freely with you guys, thanks so much.
Henry Bair: [00:58:19] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program, notes and transcripts of all episodes at www.theDoctorsart.com. If you enjoyed the episode, please subscribe rate and review our show available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:58:38] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in health care who would love to explore meaning in medicine with us on the show. Feel free to leave a suggestion in the comments.
Henry Bair: [00:58:52] I'm Henry Bair.
Tyler Johnson: [00:58:53] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.