Conversations about end of life: A family physician’s perspective
News & Updates | October 7, 2022 | Sarah Dobec
Dr. Jonathan Reggler is a family physician as well as a medical assistance in dying (MAID) assessor and provider; he lives and practices on Vancouver Island. Dr. Reggler is the co-chair of Dying With Dignity Canada’s Clinicians Advisory Council and a former board member. As part of our efforts to encourage people across the country to have discussions about end of life and document their wishes, Dr. Reggler shared his insight as a family physician on the topic.
“As a family doctor I have a system; when my patients reach the age of 75, I have a routine conversation with them about two things: one, what would they like medical services to do if they were to have a cardiac arrest – would they like them to attempt to restart their heart or not – and two, what is their attitude towards MAID? I’m not asking if they would want MAID in the future but rather, if in the future we are having a conversation about end-of-life options would they like me to include information about MAID?”
Dr. Reggler shared that his patients’ answers often change over time, but he likes to start the conversation with everyone when they reach the age of 75. Interestingly, but not surprisingly, most of his patients do not have Advance Directives* in place, and very few bring up end-of-life planning.
“People do not like to think about death – their own or a loved one’s – so Advance Care Planning and documenting wishes are unfortunately rare. I encourage my patients to think about it and I even share a brochure on our provincial system, but I have not had a single Advance Care Plan handed back to me. It may be seen as a level of formality that people don’t want or are not prepared to discuss.”
It is understandable that people do not want to think about, or talk about death and dying, but there are great benefits from doing the work early on. Similar to a will dealing with a person’s estate, an Advance Directive makes it clear what health care a person wants, or does not want, when they cannot speak for themselves. This can help avoid disagreements among family members. Dying With Dignity Canada provides an Advance Care Planning Kit that guides you step-by-step through the process of considering and recording your wishes.
Conversations about health care, and particularly about end-of-life care, come down to knowing all your options and having accurate information so that you can make an informed decision.
“Once a patient is in their last stages of life, the conversation becomes about what those stages could look like and what their options are. When possible, I like to talk to the patient as soon as possible, especially if they are considering MAID because the paperwork and assessments take time. Of course, each patient’s case is unique, and everyone has different values. I have known some of my patients for almost 20 years, so I approach these conversations with care. What is most important is that they have the information they need to make an informed choice.”
Dr. Reggler shared a story about a religious patient who was in a great deal of pain and dying of lung cancer. “One of the advantages of a MAID assessment is we can often spend two hours with a patient and learn about their family, values and wishes. I always ask if the person is religious or spiritual. This patient was religious, and I asked him if he was worried about choosing a medically assisted death because of his faith. His response was yes, but he thought he had no other option to end the pain. I was able to tell him about palliative sedation. He was not aware of this option, and immediately said, “That’s what I want.” Palliative sedation drugs lower your level of consciousness to relieve intolerable symptoms. Its intent is not to hasten your death, but to provide comfort in the final stages of your life. With all the information, this patient was able to choose his final days in accordance with his spiritual beliefs.”
End-of-life decisions can be complicated by the values and beliefs of family members, which is a great incentive for everyone to talk about and document their own wishes. “In cases where family members do not agree with a patient’s decision, it can be awkward, but I remain supportive of the patient. In some cases, the family has a lack of understanding of what is happening to their loved one, and I am able to explain the situation and offer some clarity to help explain the patient’s choice.”
Talking about our end-of-life wishes is uncommon and not prioritized by many. The irony is, it’s the one thing we all have in common, we are going to die. By starting conversations with your primary health care provider and family (biological or chosen) you offer a clear idea of what is important to you, and you ease some of the pressure at an already stressful time.
You can begin the process by downloading Dying With Dignity Canada’s free Advance Care Planning Kit.
*The term used for Advance Directive may be different depending on the province or territory in which you live.