As we prepare to celebrate New Year’s Eve, I’d like to look back on some legislation passed earlier this year (in 2015). The Quebec Government put in place a process under which competent adults can set out their own advance medical directives (AMDs).
Advance medical directives are a way of expressing one’s wishes in anticipation of incapacity to consent to care…
Specifically, advance medical directives are contained in a written document in which a person of full age who is capable of giving consent to care specifies in advance the medical care that they will agree or refuse to receive in the event that they become incapable of giving consent to care in specific clinical situations.”(1)
This new process follows Quebec’s 2014 Act Respecting End-of-Life Care, which:
sets out an overall, integrated vision of palliative and end-of-life care. It ensures that persons at the end of life can have access to quality care and support to suit their situation in the final stage of life, particularly by preventing and relieving suffering.”(2)
This was part of the Provincial Government’s recognition of “the rights of persons at the end of life, and the organization and framework of end-of-life care” and of “the primacy of freely and clearly expressed wishes with respect to care, in particular by establishing an advance medical directives regime.”(2)
The AMD process itself is deceptively simple; the individual logs on to a secure governmental website, prints a PDF form, checks the appropriate boxes, and then mails it to the Provincial Government’s Department of Health & Social Services (the Régie de l’assurance maladie du Québec or RAMQ).
I used the term deceptively simple because there’s no medical guidance or counseling provided to those completing the AMD form. In my view, there’s a likelihood that a number of these forms will be completed by individuals who haven’t fully understood the impact of the questions.
To prevent this, I feel that there should at least be a suggestion to discuss this form with one’s family physician or another medical professional who could explain the implications of each yes/no checkbox.
You might feel that I’m arguing for too much paternalism in patient protection; that people are able to make their own healthcare decisions. And I’d normally agree with you. Except that, in the case of AMDs, we are literally discussing life or death decisions. Likely being made without a clear understanding of what each choice entails.
I strongly believe that individuals are able to decide for themselves what their wishes would be in a terminal situation; my concern is that they misunderstand the medical implications of some of their responses to these questions.
For anyone
not familiar with AMD forms, these permit a person to – in advance of any
injury or illness – accept or refuse certain medical interventions should they
become incapable of giving their consent.
The Quebec Government’s version of the AMD form covers only 5 specific clinical
treatment situations, at time of either an individual’s end of life or of
severe and irreversible loss of cognitive functions:
- cardiopulmonary resuscitation (CPR)
- ventilator-assisted respiration (mechanical breathing)
- dialysis
- force-feeding and hydration
- artificial feeding and hydration
Perhaps patients will raise the topic of AMD with their own physicians. What I would have liked to see would have been to have these conversations initiated in family practice, with a specific billing category for AMD discussions. Because the best time to have a calm and reasoned discussion of one’s end of life may well be when one is healthy…
References:
(1)
Government of Quebec. Advance Medical Directives. Commission on end-of-life
care (La Commission sur les soins de fin de vie). Online. Accessed 31 Dec 2015.
Web:
https://www.quebec.ca/en/health/health-system-and-services/end-of-life-care/advance-medical-directives/
(2)
Government of Quebec. Act Respecting End-of-Life Care. Commission on
end-of-life care (La Commission sur les soins de fin de vie). Online. Accessed
31 Dec 2015. Web:
https://www.quebec.ca/en/health/health-system-and-services/end-of-life-care/act-respecting-end-of-life-care/