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Of dilemmas and tensions: a qualitative study of palliative care physicians’ positions regarding voluntary active euthanasia in Quebec, Canada

Emmanuelle Bélanger, 1 Anna Towers, 2 David Kenneth Wright, 3 Yuexi Chen, 4 Golda Tradounsky, 5 Mary Ellen Macdonald 6

Additional material is published online only. To view please visit the journal online

(http://dx.doi.org/10.1136/

medethics-2017-104339).

1 Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice, School of Public Health, Brown University, Providence, Rhode Island, USA 2 Department of Oncology, McGill University, Montreal, Quebec, Canada 3 School of Nursing, University of Ottawa, Ottawa, Canada 4 Palliative Care McGill, McGill University Montreal, Montreal, Quebec, Canada 5 Department of Family Medicine, McGill University, Montreal, Quebec, Canada 6 Faculty of Dentistry, McGill University, Montreal, Quebec, Canada

Correspondence to Dr Emmanuelle Bélanger, Center for Gerontology and Healthcare Research, Department of Health Services, Policy and Practice School of Public Health, Brown University, Providence, RI 02912, USA; emmanuelle_belanger@brown. edu

Received 21 April 2017 Revised 22 July 2018 Accepted 8 October 2018

21 April 2017 Revised 22 July 2018 Accepted 8 October 2018 © Author(s) (or their employer(s))

© Author(s) (or their employer(s)) 2018. No commercial re-use. See rights and permissions. Published by BMJ.

To cite: Bélanger E, Towers A, Wright DK, et al. J Med Ethics Epub ahead of print: [please include Day Month Year]. doi:10.1136/

medethics-2017-104339

AbsTrACT Objectives In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation? Methods We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec. results Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients’ autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death. Conclusions This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

InTrOduCTIOn

In December 2015, the Canadian Province of Quebec enacted legislation that added euthanasia as a legal option among end-of-life interventions. 1 Law 2 permits the deliberate injection of lethal medica- tion by a physician when a request has been made by a terminally ill, cognitively apt adult patient, and has been approved by two independent physicians. 2 Quebec was the first and only Canadian province to pass such legislation, although a parallel process led the Canadian government to develop a federal law in compliance with a 2015 Supreme Court Ruling, which found existing prohibitions on assisted death to be violations of fundamental rights and freedoms,

and therefore unconstitutional. 3 Together, these two legal processes resulted in a legal framework for deliberately hastened death (ie, ‘medical aid in dying’) in Quebec and Canada. The Quebec legis- lation is particular because it explicitly confers to all citizens a positive right to receive a deliberately hastened death, assuming they qualify for and wish to receive this intervention: ‘Every person whose condition requires it has the right to receive end-of- life care’, where ‘end-of-life care means palliative care provided to end-of-life patients and medical aid in dying’. ‘Medical aid in dying’, as it is referred to in the Quebec legislation, 2 is consistent with voluntary active euthanasia (VAE) as it is known in the international literature. For clarity, VAE will be used throughout this paper. Palliative care is care that promotes quality of life for patients and their families when facing a life-threatening illness through the relief of phys- ical, psychosocial and spiritual suffering. The inclu- sion of VAE as an end-of-life care option contradicts the ethos of palliative care philosophy, at least insofar as palliative care neither hastens death or prolongs life. 4 Observation of advocacy efforts by the Quebec palliative care community during the legislative consultations that led to the legalisation of VAE provides insight into its normative stance on this practice. For example, in 2014, the Cana- dian Society of Palliative Care Physicians and the Quebec Palliative Care Network expressed concern about the blurring of boundaries between palliative care and medical aid in dying in an early draft of the law. The palliative care community was successful in advocating that the definitions of VAE and of palliative care be completely separated in the final version. They were also successful in persuading the government to exempt free-standing residen- tial palliative care facilities from having to provide VAE to patients who would request and otherwise qualify for this option. Hospital-based palliative care units, however, were not exempt. 2 Several articles have addressed the attitudes of physicians towards euthanasia, but few have focused on physicians with palliative care expertise. 5 6 For instance, in a survey of 914 Belgian physicians, 90% of respondents agreed that ‘the administra- tion of life-ending drugs at the explicit request of a patient is acceptable for patients with a terminal disease with extreme uncontrollable pain or other uncontrollable suffering’ (p583), and there was no relationship between agreement with this state- ment and self-reporting any palliative care training

state- ment and self-reporting any palliative care training Bélanger E, et al . J Med Ethics

Bélanger E, et al. J Med Ethics 2018; 0:1–6. doi:10.1136/medethics-2017-104339

any palliative care training Bélanger E, et al . J Med Ethics 2018; 0 :1–6. doi:10.1136/medethics-2017-104339

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in either basic training or continuing education. 5 Conversely, a survey of 3299 American oncologists suggests that those who feel comfortable providing end-of-life care are less likely to report having performed euthanasia or assisted suicide. 7 Zenz et al also found that a majority of palliative care professionals in Germany would refuse to perform euthanasia. 8 Research in the USA, where a number of states allow physi- cian-assisted suicide (PAS) but not VAE, also highlights the challenges that palliative care providers have faced when imple- menting different state laws. A study of hospice policies regarding PAS in the states of Oregon and Washington revealed that although hospices do not participate directly in hastened deaths, there were inconsistencies and dilemmas regarding their role in providing information, in participating in the decision-making process and in accompanying patients. 9 10 Finally, according to

a qualitative study from Switzerland, where requests for assisted

suicide are managed by right-to-die societies in parallel to the

healthcare system, palliative care providers reported advising patients who made requests, but most refused to write lethal

prescriptions. 11 The authors report that participants struggled to reconcile their commitment to palliative care principles with patients’ wishes to exercise their autonomy. 11 Much has been written in the media about the opposition of key palliative care actors to euthanasia in Quebec, 12 but there remains little academic research on these views. In a study about palliative care physicians’ perspectives about specific end-of-life care practices in Quebec, VAE was viewed as falling outside of what should be considered the scope of palliative care prac- tice. 13 Policy-makers and the public, however, are surprised by the opposition of palliative care providers towards VAE. 14 This opposition deserves to be explored further, especially given that

it will have implications for the implementation of the provincial

legislation in practice. In this study, we aimed to capture the perspectives of a key stakeholder group as the law in Quebec was changing. The research question guiding this investigation was the following:

How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provin- cial legislation? An indepth understanding of the moral perspec- tives of palliative care physicians about euthanasia is essential to move forward in the planning and delivery of ethical end-of-life care in the new legislative context. Such movement will need to account for the challenges that palliative care physicians are likely to face to their moral integrity when confronted with requests for euthanasia.

TheOreTICAl frAMewOrk And MeThOdOlOgy

In this study, the methodology of interpretive description was selected to ensure a thorough depiction of the positions of palli- ative care physicians. Interpretive description is an inductive analytical methodology that can provide indepth descriptions and interpretation of data to answer research questions about clinical practice. 15 This methodology is being used increasingly in health science research because it is responsive to the expe- rience-based questions of interest to practice-based disciplines. As we explored the data, however, it became clear that some of the positions of palliative care physicians on this topic were contradictory, and that a theoretical framework would help us unpack these findings further. Therefore, we borrowed the theoretical notion of ideological dilemmas from the field of social psychology. 16 Ideological dilemmas refer to the tensions and contradictions that occur between peoples’ values and commitments, revealed in the way they talk. This concept has

mainly been examined in the context of rhetorical analysis. We explored the positions of palliative care physicians and focused on the dilemmas within their narratives, in order to consider the multiple ways in which their own perceptions of moral integrity are challenged by the recent legislative changes. The assumption is not that participants might be disingenuous or confused in positioning themselves, rather that they are negotiating poten- tially conflicting identities and expectations.

data generation and analysis

Data sources consisted of semistructured interviews. A resi- dent in palliative care (YC) and a palliative care physician and researcher (AT) conducted the interviews throughout 2015. Interviews were audio-recorded with participants’ consent and were transcribed verbatim. During the field research period, the Quebec Parliament adopted Law 2, which added VAE as an end-of-life care option, and the Supreme Court of Canada ruled that existing prohibitions on both PAS and VAE were uncon- stitutional. 2 3 Some participants were therefore approached for follow-up interviews to update their positions and react to current changes. The interview guide is provided in the online supplementary appendix. Analysis was led by a health services researcher with specific expertise in qualitative research (EB), without affiliation with palliative care organisations. Transcrip- tions were analysed in several iterations by the first author and following discussions with the entire research team. Analysis was conducted in accordance with interpretive description and also guided by the theoretical framework, as we examined the emerging themes for contradictions and dilemmas, and consid- ered what these might reveal about the ideological commitments and moral positionings of our participants. The NVivo qualitative analysis software was used to help manage the data. Data collec- tion and analysis occurred concurrently in an iterative process, to enhance understanding and to permit deeper probing into the issues at hand. Thematic categories and dilemmas regarding these categories were found through a consensual process of discussing excerpts involving all the authors. The researchers met regularly to ensure a uniform data analysis process and to confirm the emerging thematic categories. Participants signed informed consent forms guaranteeing their confidentiality.

resulTs

Eighteen palliative care physicians participated in the study; they represent the majority of the palliative care physicians on staff at the palliative care units of two public hospitals located in an urban area of Quebec. All participants were full-time palliative care physicians, and like most palliative care providers in Canada the majority of them (16 out of 18) were family physicians. As expected, all participants expressed discomfort with euthanasia as an aspect of end-of-life care. All but one denied the influence of religious or political positions in shaping their views. At a surface level, their shared discomfort is consistent with position statements from palliative care associations. Further, though, our participants felt that the richness of the issue was lost when the debate was framed in binary terms. Ultimately, participants’ normative stances about VAE cannot be reduced to simply being ‘for’ or ‘against’. As one participant said, “There is this attitude from the palliative care community that, you know, there’s no discussion, we know how to take care of patients, and, you know, [those performing VAE] are killing patients. So I don’t think it’s as black and white as that’ (participant 7). Our findings suggest that there were recurrent dilemmas in the ways that palliative care physicians positioned themselves on this issue, as members

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of a professional community of palliative care and as members of Quebec society. As we explored the justifications that palliative care physicians gave to explain their position against the new medical aid in dying law, we also found areas of uncertainty and ambiguity.

Professional roles versus a person’s right to choose

As healthcare providers pursue their training, they adopt the norms, values and behaviours of the professional groups they aspire to belong to, and integrate them with their background and pre-existing personal identities and experiences. Controver- sial issues such as VAE raise the challenge of personal conscience and of potentially conflicting positions between personal and professional positions. Participants reported not having a problem with individuals choosing euthanasia for themselves, thereby making their own decisions:

I feel that it’s an extremely personal choice, I feel that part of some of the resistance at times can be related to [the fact that] that this is something new. Would I practice euthanasia? No, I would not be able to do it. […] I think it’s a very dangerous thing. I think on an individual level, it might make sense, but I think on a societal level, I think it sends a … message. I worry about what it sends [as a message]. But do I have the arrogance to think that someone should not have something that they want? (participant 3)

The arguments that participants used to justify a position against euthanasia were framed within their professional roles, which could then contrast with their respect for patients’ autonomy to choose end-of-life options. “I can see that it’s a very personal view, and there is not a single way of seeing things. Therefore when you ask me if I’m in favor or not of the Bill, it’s very hard to answer. Obviously based on my own beliefs, I don’t want to use that right, but I cannot say that it’s wrong for other people to use that right” (participant 6). Overall, their concern for the integrity of the palliative care profession prevailed as they discussed their own positions on VAE. As will be explored below, tension became more prominent when the practice of euthanasia explicitly conflicted with their professional roles.

euthanasia as impeding the evaluation of suffering

The analysis revealed a tension between the need to explore patient suffering in order to alleviate it and the need to respect patient choices even when shaped by the extent of that suffering. Participants reported occasionally encountering demands for a hastened death in their practice and interpreting those demands as a plea to explore the patient’s suffering. There was concern that once VAE would be legal, palliative care physicians would no longer be able to explore requests for death in as much depth. There was concern that with euthanasia as an option, their patients would be less willing to allow them the time and the engagement required to address suffering adequately and explore other care options. This concern revolved around the implementation of the law, which guarantees rapid access to euthanasia after a patient request. Taking the time to explore and palliate suffering was presented as a fundamental component of palliative care practice:

When someone asks for hastened death, I spend time with them, I try to explore the question, I try to explore existential, physical, emotional and psychological things, we all [palliative care physicians] put in a lot of effort in trying to figure it out. I think if euthanasia is available, I’m not sure if that person really wants me to spend that time. It may actually be easier in a sense, I will have less work but I’m not sure that it will be, you know, I will feel bad

for the patient, because you always wonder like, maybe we could’ve done something, maybe they would have stopped asking for that. I will feel like the patient is not getting the best care. (participant 8)

In the following excerpt, the same participant defends the contrary position of accepting and understanding a patient’s choice. “I wouldn’t choose against the patient. […] I’d feel for

the patient, they are choosing it because they are suffering, and they don’t necessarily want to choose it but they are choosing

it because they are suffering and they believe that that will help

them suffer less” (participant 8). There was an inherent tension

between respect for autonomy and what they perceived to be the time required to provide good-quality palliative care.

Concern that VAe legislation is a policy response to poor- quality end-of-life care

Participants were concerned that VAE legislation was, at least partly, developed in order to fix a broken healthcare system: that is, it was being offered instead of working to improve the quality of palliation and symptom control. In the excerpt below, the desire for a hastened death is seen to make sense when embedded in a patient’s desire for control; however, it becomes problem- atic when it is a response to poor access to palliative care.

I think that as an individual, I would feel a certain level of comfort in knowing that I had that degree of decision or control of my life. […] I think that professionally I’m very uncomfortable with it, as an option in the current state of the health care system in Canada, as I feel that many individuals within the greater society in Canada do not have the ability to make fully autonomous choices. I think there are many external factors that affect people and even as simply as the access to palliative care. (participant 15)

Participants acknowledged that some patients might indi- vidually want euthanasia when faced with poor health services and uncontrolled symptoms; however, they felt that this was not a situation that should be condoned socially and profes- sionally. Participants asserted that they could not condone VAE as a policy response to a healthcare system that provides poor end-of-life care. As professionals closely involved with accompa- nying patients at the end of life, they suggested that expanding access to palliative care was an important prerequisite and they did not believe that Law 2 would improve access despite explicit engagement to do so in the provincial legislation.

Potential of palliative care to provide peaceful deaths

A contention that there was a lack of knowledge about palliative

care among both the general public and other healthcare profes- sionals was evident throughout the interviews. Participants felt there to be a need for better end-of-life care in our society and felt themselves best placed to address this need. As such, they commonly mentioned the lack of knowledge about palliative care and the fear of dying that is present in the general public.

In a sense, I do understand why some people are supporting this Bill. It’s because people want to have control over their lives, and so control over their death as well. That may stem from their fear of losing that control at end of life, suffering and not being able to make decisions for themselves. I do understand where they come from. But on the other hand, I do think there are ways we can work around that, I think people need to be educated about what palliative care is. A lot of people may not be aware of what we do. In a sense, they see it as black and white. Either I live a happy life, healthy no suffering; if I suffer, then I need to terminate my suffering myself, instead of having a team of professionals whose job is to help relieve that suffering. (participant 5)

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The notion that causing patients’ death directly is not necessary to relieve suffering was also prevalent in the interviews. “People who actually deal with patients who are dying are opposed to the Bill. Why? Because we don’t see it as a great need. We are

able to treat patients and we’re able to alleviate their suffering. And for the most part, do so without even having to sedate them in a continuous manner” (participant 2). Participants felt that the public and policy-makers were not aware of the potential of palliative care to relieve suffering and help patients attain

a peaceful death. There was an understanding of the societal

need that came from this lack of knowledge about palliative care and of the distress that came with it, even among health professionals. The fear of dying and of suffering is a powerful force that has to be addressed with public policies. “Everyone’s afraid of dying. Everyone’s afraid of suffering. So I think to put together a Bill that would sort of meet the needs of the popula- tion, I think makes sense” (participant 2). However, even when acknowledging the challenge of alleviating pain and suffering, participants emphasised that there is already an ethically accept- able treatment, palliative sedation, that can be used in the rare cases where suffering endured: “Now, statistically speaking, are there some people who persist in asking for it? Will there be some people I can’t manage their symptoms so they will persist in asking? For sure, but it hasn’t happened really that often and […] palliative sedation was an option” (participant 8).

reconciling accompaniment without participation in hastening death

There was a general agreement among participants that palli- ative care should neither hasten nor delay death, and should

therefore remain separate from the implementation of the new provincial legislation. Further, there was agreement that pallia- tive care physicians should not be involved because participants felt it would threaten the therapeutic relationship and reduce trust: “I have great concerns as to how that makes a population feel that they can trust the health care system” (participant 3). However, participants were also aware that as physicians, they have expertise which could help ensure that euthanasia would be carried out without inducing more suffering than necessary.

A major dilemma for the participants appeared to be the need to

remain true to the definition of palliative care, not abandoning patients and continuing to care for them even if they requested euthanasia. For some, this meant removing VAE patients from the palliative care units; for others, this was problematic: “I would question the not-doing-it-on-a-palliative-care-unit, if the

patient has been trying palliative care and it hasn’t, to their mind, been successful. Or, at this point, they want to then make use of euthanasia; it seems a bit harsh to me to then somehow transfer them off of the palliative care unit to be killed, you know, some- where else” (participant 4). The question of who should be in charge of providing VAE was a persistent one, one which few participants had an answer to, beyond “not us, palliative care

physicians”:

I don’t know that I have that expertise and I don’t know that

I feel that I’d be capable and competent to do that really. That

being said, I’m torn, because who is it going to be? Is it going to be

some person they are going to hire that’s going to be a euthanasia specialist? Is it going to be like a pharmacist-driven thing? Who else would be the best advocate to do it? So at the same time, I’m so utterly protective of humanity and patients, especially the ones that have no mandate, that have nobody, I worry about who would be that identified person. Who would be that competent person? So the answer is, wow, I don’t know. (participant 3)

dIsCussIOn

This study provides insight into the nuanced positions of expe- rienced palliative care physicians in Quebec during the adoption of a provincial legislation about VAE. The integration of VAE and PAS in palliative care practice remains a highly contentious topic. 14 17 In this study, in addition to a concern for patients’ right to choose, the position that prevailed was one of professionals with a commitment to improving the state of end-of-life care and to promoting awareness about the potential of palliative care to provide adequate symptom control and maximise opportunity for valuable end-of-life moments. Few studies have focused on the attitudes of palliative care providers and how they position themselves beyond the official position of professional associa- tions. We identified dilemmas that appeared when justifying an opposition to VAE, which were framed within professional roles and contrasted with positions that emphasised personal prefer- ences, and patients’ autonomy and right to choose. In our data, participants acknowledge that positions are deeply personal, but justified their opposition as part of their professional roles and palliative care values. Participating physicians did not explicitly align with religious or politically conservative agendas, contrary to a Belgian study. 5 Similarly, Lavoie et al did not find religious affiliation to be associated with the intention to practise eutha- nasia among Quebec physicians. 18 Participants perceived that truncating the dying process undermines the value of end-of-life experiences and that desire for hastened deaths implies a lack of awareness of the potential of palliative care to provide peaceful deaths. Their perspectives resonate with the position of the International Association for Hospice and Palliative Care and the European Association for Palliative Care, both of which recommend that requests for a hastened death should be addressed as part of palliative care practice through interventions that can help relieve suffering, such as palliative sedation. 19 20 The advocacy notion that eutha- nasia would not be necessary if access to palliative care was adequate was identified in a previous discourse analysis of Cana- dian physicians’ positions in the print media. 12 Although often not explicitly stated in official position statements, this theme implies that palliative care is able to create value at the end of life. Dying is presented as a ‘natural’ process that should be neither hastened nor delayed. The palliative care movement seeks to restore meaning and dignity at the end of life. 21 This movement has historically positioned itself in opposition to assisted death, although this positioning is not without controversy. Bernheim and Raus, 22 for example, argue that criticisms of the Belgian model of end-of-life care (which integrates both euthanasia and palliative care) fail to consider that ‘there is a plurality of reason- able and defensible views on the ethical acceptability of eutha- nasia’ (p493). For these authors, respecting patient autonomy in a way that makes room to consider euthanasia as an ethical option in some cases is a more authentic way of enacting empathy (a core palliative care value) than rigid adherence to historical or doctrinal positions of outright moral rejection. The work of Quebec’s Commission on Dying with Dignity that took place in 2010–2011 was central to the development of the medical aid in dying legislation in the province. This Commis- sion explicitly concluded that end-of-life care is inadequate in the province, and therefore euthanasia should be provided as an option for patients who are inevitably suffering as a result. 23 In our study, participants described euthanasia as an inappropriate response to poor-quality end-of-life care, one that was also incompatible with their professional role as palliative care physi- cians. This point again aligns with associations that advocate

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against the decriminalisation of physician-assisted death in the absence of universal access to palliative care. 19 20 The main ethical issues that have been raised in previous work surrounding the provision of physician-assisted deaths in the context of insuf- ficient access to palliative care services concern the absence of meaningful choice, the risk of health inequity regarding access to care and the development of VAE as a potential barrier to the development of palliative care. 24 Yet emerging evidence indi- cates that the decriminalisation of euthanasia has not impeded the development of palliative care services in Benelux coun- tries. 25 In cases reported in the Dutch-speaking part of Belgium, there appears to be an increase in the percentage of euthanasia cases where palliative care was consulted, from 34.0% in 2003 to 42.6% in 2013. 26 However, a unique feature of the Belgian context may be synergy between the euthanasia and the palli- ative care movements, something that has not been observed elsewhere. 27 A remarkable feature of the situation in Quebec is the tension inherent in Law 2, which includes VAE as an option on the continuum of medical care at the end of life, despite the opposition of palliative care providers who provide a large part of this care. 14 The findings of our study speak directly to ongoing debates regarding the integration of euthanasia into modern notions of ethical end-of-life care, specifically with regard to the role that palliative care providers ought to play in the care of patients requesting and/or receiving euthanasia. In this paper, we high- lighted dilemmas apparent in participants’ narratives about reconciling respect for patients’ right to choose their own deaths with palliative care values, and about accompanying patients who make requests for euthanasia while remaining committed to neither prolonging nor hastening death. Our findings show that palliative care providers are sensitive to a host of ethical issues at play in the care of patients seeking euthanasia, including (but not limited to) the limited access to palliative care that many patients face, and the time that it takes to provide adequate end-of-life care to people who are suffering, as well as the value of non-abandonment for ethical therapeutic relationships. Lack of time to properly evaluate suffering and provide the stan- dard of care that palliative care providers feel patients need and deserve puts such providers at risk of experiencing moral distress. 28 Regarding non-abandonment, a similar concern was also documented among Swiss palliative care physicians, who found it difficult to accompany patients in decision-making about assisted suicide while honouring palliative care principles that do not support this practice. 11 Interestingly, the theme of non-abandonment figures among the reasons that US physicians provide for supporting the decriminalisation of euthanasia. 29 Research in the Netherlands has shown that tension between what physicians consider to be a good death and patients’ views and preferences can have significant implications for the imple- mentation of physician-assisted death. 30 It is worth highlighting that the majority of arguments mobilised by participants were also identified in a review about the moral issues surrounding euthanasia as presented in palliative care journals. 31 Arguments about dying as being a part of life, euthanasia diverting atten- tion from good palliative care, as well as the non-necessity argu- ment when receiving good palliative care were encountered in the data. The dilemmas documented further shed light on the challenges involved in upholding these principles while also respecting autonomy, being compassionate and acknowledging the fallibility of palliative care. 31 Less attention was paid to the slippery slope argument or the dehumanisation that can result from a culture of death, perhaps because participants were not envisioning VAE as part of their palliative care practice. Given

that foundational ethical principles of palliative care and physi- cian-assisted death appear to be at odds for a majority of profes- sional palliative care associations, some argue that the practical implications of decriminalisation for palliative care services should have been taken into account explicitly as part of legisla- tion to minimise conflict in implementation. 17 At the same time, other critics observe that continued and unequivocal rejection of euthanasia by the palliative care community will only result in the marginalisation of palliative care within euthanasia-permis- sive jurisdictions. 22 Our participants perceived tensions between their personal and professional identities, which undoubtedly will have impli- cations for their self-evaluations of moral integrity. Exposing the nuanced views of stakeholders who are heavily involved in providing end-of-life care is meant to contribute to further ethical analysis and debate on this topic, especially in the light of recent considerations by Quebec and Canadian governments about potentially broadening access to medical aid in dying to cognitively impaired adults through advance directives. The end of life is often depicted as unavoidably painful and undignified in public debate, with what appears to be limited awareness of palliative care practice. The role of palliative care providers in the implementation of physician-assisted deaths remains unre- solved. Regardless of whether or not the law is expanded over the coming years, there is no doubt that more research is needed to assess the impact of this provincial legislation in the context of the Quebec healthcare system. This impact will undoubtedly be shaped by the degree to which palliative care providers are involved, or not, in the care of these patients moving forward. This study has certain limitations. First, participants were interviewed by either a palliative care resident or a palliative care physician, which might have triggered social desirability and affected responses. However, questions were open-ended and confidentiality was guaranteed; it is reasonable to assume that we obtained authentic responses. In addition, an independent health services researcher (EB) led the analysis with the input of team members who have a diversity of viewpoints, including as palliative care providers (nursing, medicine) and researchers with training in social science and bioethical approaches to health research. The presence of dilemmas and of nuanced answers conveying uncertainty also suggests that participants could adopt any position. Another limitation is that the physi- cians involved in this study take care primarily of patients with cancer. While this is transferable to the practice of other pallia- tive care providers in the province, the views of physicians who are not primarily palliative care providers but who still provide palliative care to patients who have other diseases might be different. For instance, patients with neurodegenerative diseases such as amyotrophic lateral sclerosis have contributed signifi- cantly to the development of current euthanasia legislation in Canada and largely die under the care of neurologists unless they are transferred to palliative care units. Finally, all participants practised palliative medicine in one urban area of Quebec, and early evidence of implementation practices suggests that there may be disparities in access to VAE across regions, suggesting that clinicians working in other regions might have different opinions; conducting similar research in different regions would be informative. In conclusion, this study documented the dilemmas and tensions that palliative care providers face when discussing the inclusion of euthanasia as an end-of-life care option in the Prov- ince of Quebec. These positions highlighted some of the struggles inherent in reconciling commitments to values—such as respect for autonomy—with broader identities that are shaped within a

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disciplinary context, one that opposes hastened death. Insofar as palliative care providers are a major stakeholder of end-of- life care in Quebec, we need to further explore how the policy allowing euthanasia is shaping the practice of palliative care and the evolving role of palliative care providers more generally when faced with patients who request a hastened death.

Contributors AT and YC planned the study and conducted the semistructured interviews with the participants. YC conducted the descriptive content analysis of the material. EB conducted the first iteration of interpretive analysis and prepared the material for discussion with all coauthors before the next iteration of analysis. All authors contributed substantially to reporting the work through direct input about organisation of the argumentation, quote selection and discussion of relevant literature. EB and AT are responsible for the overall content of the article as guarantors.

funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests None declared.

Patient consent We used the standard consent forms from the IRB that reviewed the study.

ethics approval

University Health Centre approved this study.

Provenance and peer review Not commissioned; externally peer reviewed.

The Institutional Review Board of the hospitals involved and McGill

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