Palliative Interventions

Palliative care is an approach that improves the quality of life of patients and their families facing the problems associated with life-threatening illness. The focus of care is on controlling pain and other symptoms. Serious illness and dying can also bring emotional, social, and spiritual problems.. Your doctors and others caring for you want to make those less difficult as well. They want to give you and your family the best quality of life possible.

 

What are palliative care practices?

Palliative care includes medical practices that aim to give you relief from pain or other suffering. For example:

  • drugs for pain
  • oxygen
  • feeding through an IV or a tube in the nose
  • blood products
  • drugs for nausea (or feeling sick to the stomach)
  • drugs for anxiety

Palliative care can also include counseling and spiritual support.

While all palliative care aims to help you to be as comfortable as possible, two practices that can be part of palliative care may also bring death more quickly. These are called “potentially life-shortening opioid use” and “palliative sedation.”

 

What is potentially life-shortening opioid use?

Doctors commonly treat pain near the end of life by giving opioids. Opioids are drugs used to treat serious pain. They include morphine, codeine, meperidine, and oxycodone.

Opioids can do several things. They can block pain. They can make you feel sleepy. They can relax your muscles. They can also slow down your breathing.

In very rare cases, the amount of the drug needed or the speed at which the drug needs to be given to control your pain may slow breathing so much that it hastens death. In very rare cases, doctors will not be able to tell how much of the drug can be given or how fast it can be given without hastening death.

 

Is potentially life-shortening opioid use legal?

Canadian courts have said that it can be legal for a doctor to give a patient opioids to manage pain and other forms of suffering — even enough that they know could hasten death.

The Supreme Court of Canada said in the Sue Rodriguez case in 1993 that palliative treatments that could shorten life are not illegal. If a doctor eases pain by giving drugs that they know could cause your death, it is not same as a doctor giving drugs with the goal of bringing death sooner. The difference, said the court, is in the doctor’s intention. The court said that legally the difference is clear.

Similarly, in 2012, the Supreme Court of British Columbia wrote in Carter v. Attorney General (Canada) “potentially life-shortening symptom relief is permissible where the physician’s intention is to ease pain.”

 

What is palliative sedation?

Palliative sedation has been defined in two different ways. Some people define it as giving a patient drugs that cause them to lose consciousness. Others define it as giving a patient drugs that cause them to lose consciousness and stopping any IV fluids and artificial nutrition.

Your doctor might suggest that you or your family ask for palliative sedation when there is no other way to relieve your suffering.

 

Is palliative sedation legal?

If a doctor gives deep and continuous sedation and continues IV fluids and artificial nutrition, this is clearly legal.

However, if a doctor gives deep and continuous sedation and stops IV fluids and artificial nutrition, this may or may not be legal. That will depend on how far away from death the patient is.

Deep and continuous sedation without IV fluids and artificial nutrition is clearly legal when the patient is very close to death. “Very close to death” means death is expected within a couple of days. Any withholding or withdrawal of IV fluids and artificial nutrition would in no way cause the patient’s death.

Deep and continuous sedation without IV fluids and artificial nutrition is likely legal when the patient is close to death. “Close to death” means death is expected within a couple of weeks.  Any withholding or withdrawal of IV fluids and artificial nutrition would be unlikely to cause the patient’s death.

Deep and continuous sedation without IV fluids and artificial nutrition may be illegal when death is not expected for many months. Any withholding or withdrawal of IV fluids and artificial nutrition would cause the patient’s death.

The Société Québécoise des médecins de soins palliatifs and the Collège des médecins du Québec have provided practice guidelines on palliative sedation at the end of life to help guide physician practice.  The Quebec National Assembly also addressed palliative sedation in its Act Respecting End-of-Life Care – establishing that Quebeckers have a right to palliative sedation but narrowly defining palliative sedation as not hastening death.

For a full discussion of palliative sedation, see: Jocelyn Downie & Richard Liu, “The Legal Status of Deep and Continuous Palliative Sedation without Artificial Nutrition and Hydration” (2018) 12:1 McGill JL & Health 29.

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