Right to die: interview with Canadian palliative care doctor Dr Sandy Buchman
“Some people will celebrate and have their living wakes or living funerals. They’ve invited guests and friends and family to say goodbye and participate. It’s changed the whole culture around death and dying in many ways.”
Dr Sandy Buchman clutches his teacup, warming up his hands from the chill of the freezing Edinburgh wind.
It may not be the subject usually discussed over a pot of tea in the lounge of a four-star city hotel – and the couple at the table next to us keep glancing over curiously – but for Buchman, the subject of dying is very much the norm.
It’s not just the fact we’re discussing dying that’s causing the anxious sideways glances. It’s the fact we’re discussing how and why Buchman helps people to die.
Buchman is one of a number of doctors in Canada practising what is known as medical assistance in dying (MAID).
A palliative care physician with 35 years’ experience, Buchman’s whole outlook on life and death was transformed almost three years ago when he decided he would help patients with terminal illnesses to die.
It followed a ruling by Canada’s supreme court in February 2015 which paved the way for doctor-assisted death. But with no requirement for doctors to do so, it is down to individual physicians themselves to opt in to the practice.
“It took well over two years for me to come to the decision that I would participate in what we call medical assistance in dying – or MAID,” explains Buchman, who is the incoming president of the Canadian Medical Association. “It was a reflective process that I did with my colleagues. I’m a physician now of 35 years’ experience and given the length of my training and time I’d been a physician, it was something I never could conceive of.
“Our goal was always to sustain life, but my palliative care training always taught me about suffering and palliative care is there to optimise living and dying.”
Buchman and his colleagues were forced to examine their own ethics as they anticipated the result of the Carter v Canada Supreme Court ruling, where the prohibition of assisted dying was challenged by several parties, including the family of Lee Carter, a woman suffering from degenerative spinal stenosis.
The result – as Buchman expected – was the legislation, introduced in 2016, which allowed anyone over 18 with a “grievous and irremediable medical condition” to apply for doctor-assisted death.
“I think we were maybe one of the earliest groups in Canada, if not the earliest, to even consider it, so it gave us a lot of time and allowed us to work in the spirit of ‘we are all in this together’ in a non-judgmental, safe framework,” explains Buchman, who wasn’t connected to the Canadian Medical Association at the time.
“Having the profession support conscientious provision as well as conscientious objection, taking this neutral stance, [it] was important to me that they would have my back and that my profession would recognise that this was OK.
“It was important for me on a personal basis to examine my role as a physician as to what my role in suffering was and what was my role in alleviating suffering, especially as a palliative care physician dealing with patients who are approaching end of life.
“It was important for me that my wife, my partner in life, be supportive of my goals. If I was going through emotional difficult circumstances, could I open up and share with her about it? It was important for me in this particular emotionally laden issue that she’d be there.
“I also have three adult sons, one of whom is a bioethicist, and I had lots of discussions with him and he was able to challenge me, so that was important to me.
“I had to look at my own faith and values and investigate that to see if it would be consistent with who I am, but ultimately, I decided that putting that altogether that I was able to do this, that I had a choice and therefore leaned to doing it.”
Buchman shared his own personal views, as well as the wider experience of assisted dying in Canada, with MSPs at Holyrood during a recent visit to Scotland.
Holyrood has seen two attempts to introduce legislation giving people the right to choose when to die, with the late Margo MacDonald’s End of Life Assistance Bill defeated in 2010 and Patrick Harvie’s Assisted Suicide Scotland Bill rejected in 2015.
But in Canada, legislation was passed on 17 June 2016 and just a short time afterwards, Buchman found himself agreeing to help his first patient to die.
The assisted death law requires two different doctors to assess the patient and confirm they are eligible as a result of having a serious and incurable disease that causes suffering the patient considers to be intolerable and that their death is “reasonably foreseeable”.
The doctors must also confirm that the patient is mentally competent to make the decision themselves and that they have not been coerced in any way.
On 15 July 2016, Buchman followed through with the wishes of Gordon Froggatt, a cardiologist with Parkinson’s disease, and helped him to die.
“When he asked me [to help him die], I wasn’t expecting it, but when he asked me, I knew this was a test of a culmination of my own process,” recalls Buchman. “I had made the decision that I would explore it and so because I had prepared by the time the legislation came in, I promised to explore his suffering in an eligibility assessment.
“Your right is just to an eligibility assessment, not to an actual procedure, you have to meet the criteria. The criteria has been established by the law in Canada.
“The experience with Dr Froggatt when I let him know I was willing to explore it with him was profound. He was a changed man because he had a grain of hope that we might be able to help him; that he wasn’t doomed to the fate that, as a physician, he knew too well what that would be. That also confirmed to me that I was doing the right thing.
“He was found eligible by another physician and his psychiatrist even confirmed it, as did a neurologist – I overdid it with him because it was the first time. So all the physicians agreed. And then when the day came to do the provision and he was so certain and his family was behind him and when I saw how peaceful it was, and so loving, it felt like it was completely consistent with who I was as a physician and as a person.
“I knew at that moment that I had done the right thing for my patient.
“I felt apprehensive, anxious, nervous…I still do. It should always be difficult. I had no regrets on any case I’ve been involved in, there’s an absolute certainty and confidence that we did that, and that’s been the experience of the families.
“They’ve been incredibly appreciative and the last words of my patients to me have been ‘thank you’.”
Buchman doesn’t keep an accurate tally of how many people he has helped to die – maybe it’s a coping mechanism, maybe he just doesn’t feel the need – but he estimates that it’s more than 20 over the time he’s been participating in MAID.
In Canada, assisted deaths have accounted for just one per cent of all deaths since the law came into effect.
Many of the people who pass the eligibility test never go through with the procedure, but just knowing they have that option is a massive relief to them.
“Patients sometimes just want the option to know it’s there,” explains Buchman. “Dr Froggatt brightened up when he knew we would explore it, even though he wasn’t guaranteed eligibility – just the knowledge that it’s an option. As we address their suffering, the vast majority will just accept the treatment.”
Once deemed eligible for assisted death, there has to be a reflection period of at least ten days to allow patients to change their minds.
“During this time it’s a fully informed consent process, but the patient has the option to withdraw consent at any time, even up to the last minute,” explains Buchman.
“The physician can abort the ten-day reflection period if they feel the patient is in danger of losing capacity, so if they’re declining, we can abort it, that’s a medical decision and we do it sooner, but that’s the only situation, if we’re afraid they’re going to lose capacity.
“Most of the time, it goes the full ten days and the eleventh day or beyond is when you can do the procedure.”
Once the date has been agreed, Buchman says that “the vast majority” of patients will have their family and friends with them before or during the procedure, which usually lasts several minutes.
“Patients orchestrate it. I’ve had patients have their choice of music in the background, from What a Wonderful World to Ave Maria. Patients plan,” he says.
“Others want it very private. And sometimes there’s humour. I had an 80-year-old woman who was requesting it and the night before we ask people to have a clear fluid diet in case there’s any nausea or anything and she said to me, ‘Is Scotch a clear fluid?’ and I said, ‘Well, technically, yes’ and so we toasted her. I didn’t have any, but the family did and toasted her with a sip of Scotch just prior.
“It’s very, very personal and sometimes there’s lots of smiles and other times it’s very sad. It’s all of those into one. There’s a mixture of emotion. Personally, I find as I’m anticipating the procedure, I’m confident and I know it’s the right decision, but I always want it to go perfectly well and I’m confident that it will, but it’s a serious thing and it’s always one that has to be reflected.”
Buchman adds: “It’s serious to be a provider and it’s hard. It stays with me. At first, I wasn’t sure how I would react. My first case, my colleagues gave me the day off. I found that because it felt so right and so consistent, that I haven’t experienced anxiety or regret or any negative emotions. In fact, I’ve felt that I’ve helped my patients in ways that I could never have helped them before. I feel better about it as a physician, as a professional, to be able to finally alleviate their suffering.”
Buchman’s presentation to a group of cross-party MSPs at Holyrood outlined some of the main issues Canada faced when legislating for MAID, including mature minors, mental illness and advance request, in order to help shape any future laws on assisted dying in Scotland.
National campaigning organisation Dignity in Dying Scotland has already been meeting with MSPs to discuss their views and the next bill to go before parliament is likely to differ from previous attempts and legislate for the introduction of assisted dying for terminally ill, mentally competent adults only.
Working with a group of MSPs from each of the parties, the charity is looking to launch a consultation on new legislation in this parliamentary session, with a bill following.
Ally Thomson, director of Dignity in Dying Scotland, says: “We know that there are too many bad deaths in Scotland and that 80 per cent of the Scottish public want to see a change in the law on assisted dying. We cannot continue to let people suffer when there is a safe alternative.
“Scotland is well placed to join other progressive countries around the world by changing the law to provide a choice to terminally-ill people to make a decision, when death is inevitable, about how they will die. Dignity in Dying Scotland is actively working with MSPs from all parties and all parts of the country to bring the right bill to parliament.”
Thomson adds: “There is an increasing momentum for change inside and outside the parliament. We are calling on our politicians to listen to the voices of dying people and look at the evidence from places like Canada and commit to fixing our broken law that is letting our dying people suffer needlessly.”
Campaigners know that if they are to bring a third bill to parliament, it needs to be right this time and gaining evidence from countries which have successfully passed legislation gives them an invaluable insight into where the potential pitfalls are.
While Buchman wouldn’t be “presumptuous” enough to suggest how Scotland should legislate, he is quick to add that whatever happens, doctors need to be involved in discussions right from the start.
“I do feel it’s very important that the medical profession needs to have a seat at the table and should be part of the conversation,” he says. “The values of each and every physician need to be respected. It’s a neutral position, it’s one which supports conscientious objection as well as conscientious provision.
“I do understand the reluctance to get involved. I was incredibly reluctant to get involved.”
He adds: “There’s two people in every assisted dying case, remember; there’s the patient and then there’s the provider.”