Canadian Medicine

Yesterday, we reported on Bill C-562, which proposes to legalize physician-assisted suicide in Canada. The Canadian Medical Association's current ethics guidelines forbid doctors from taking part in any form of euthanasia, but Dr Jeff Blackmer, the executive director of the Canadian Medical Association's , is nevertheless keeping tabs on Bill C-562 and how the public and physicians react to it.

The CMA's policy, he said in an interview this morning, could change in the future as legal circumstances and ethical debates progress. Here is Canadian Medicine's Q&A with Dr Blackmer:

What’s the CMA’s reaction to Bill C-562?

In terms of a reaction what we are really doing is keeping a close eye on these types of things, getting a sense from politicians on where this is headed. Private members’ bills generally don’t pass, so this is less an issue where we need to intervene directly than one where we need to gauge the feeling of the MPs and the House and whether this has support of the Canadian public.

So how would you gauge the feelings of Parliament and the public at the moment?

In polls there is a fair bit of support for the concept of a system whereby people can have more control over their time and place of death. The polls have increased a little bit -- they are stable, at least. What that means is difficult to gauge. There is no appetite, I think, for euthanasia on-demand right now, but instead for a more reasoned debate on how to deal with people at the ends of their lives who are ready to die, and should there be means to help them in a regulated, legislated way.

Has there been any change in physicians’ support for some form of legalized euthanasia?

My sense -- and it’s not based on solid numbers; just anecdotally -- is it has moved in that direction. I certainly don’t sense a huge upswell in the medical professio, but there is certainly more sympathy for that view. We have some physicians who are very vocal in their advocacy for euthanasia and physician-assisted suicide, and some are very opposed, but the majority think something somewhere in between. We have put a lot of focus on palliation and symptom care in end-of-life care, and we are doing a better job than five years ago on pain control. That focus will decrease the need for euthanasia and physician-assisted suicide, but we also realize there may be exceptional cases where we cannot have symptom control for various reasons. There is sympathy among physicians and public that there are cases where you can understand why people would request this. I have a relative in Nova Scotia who is dying of end-stage leukemia, and he is ready to go. His family says, ‘Isn’t it a shame that, if he were a pet, we could end his suffering?’ His family is saying they can now understand why there are proponents of people having more control over that dying process. At some point in the future I think we will do a little bit more research into this to find out how often this [physician-assisted suicide] does happen, but our sense is this is quite rare. We will have another look at that and engage the viewpoint of practising physicians, to ask would they be involved if it was legalized. One of the challenges is before you can do a study is you need some protection for physicians to get honest responses.

You believe there are doctors in Canada performing euthanasia?

I am not aware of any names. It would be a serious breach of ethics code and legislation. We have a sense, anecdotally, that it happens more on the basis of something where a physician prescribes a pain medication or an antidepressant and says, ‘If you took too many of these, here is what would happen.’ It is a warning, and some might it view as information that is required, or permission [to commit suicide]. That is more the concern rather than doctors going into people’s homes and administering an overdose. The last serious incident I remember was Nancy Morrison, in Halifax, who gave an overdose of KCl [potassium chloride] to a patient in the ICU. She was prosecuted and sanctioned by the College of Physicians and Surgeons as well, back in the 90s. There hasn’t been another high-profile case since that point in time.

Is the CMA’s policy on euthanasia and assisted suicide -- that physicians should not take part at all -- set in stone, or is it possible it could be amended in response to legislation like Bill C-562 or a change in public opinion?

Obviously that is a difficult question to answer. On these types of issues -- that is, a serious potential bill coming before the House or a serious development publicly -- we would reevaluate this policy closely. We reevaluate all ethics policies every year. If public feeling has shifted, we would ask if this is something we need to reconsider, to look at through another lens. This is an issue that has huge implications for Canadian physicians, so it would go through the CMA’s Council and committees, not just the ethics policy. We are not at that point yet but there have been enough rumblings over the past years that I could see that happening. But it is such a difficult issue on many levels that we wouldn’t reopen it to that extent unless there was a good cause or reason for it -- it is just so divisive for the public, doctors, nurses and patients that before you get into that debate, you want to make sure the time is right and it is necessary and helpful. We have a policy that is very clear, and we have no plans at the current point in time to change that policy. We wouldn’t change that simply based on a public opinion poll, but at this point we are watching to see what is happening, to decide when and if we want to reopen that debate. My sense is we are not there in the very near future, but things could happen that would cause us to have to go through some introspection.

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Counselling and treatment on smoking cessation will help smokers who are hospitalized at a cardiopulmonary hospital centre quit their habits. Right?

Wrong.

A new Canadian study that asked that question is one of those relatively rare clinical trials in which the conclusions seem self-evidently obvious but the data turn up unexpected results.

Contrary to the researchers' hypothesis, all the smoking cessation work put in by the Laval hospital's physicians -- an involved, five-step intervention that takes the study's authors most of a small-type journal page to describe -- had no discernible effect on patients' likelihood to butt out.

DISCOURAGING DATA
The (full text requires subscription) was published by a team of Quebec City-based Laval University researchers in this month's issue of the journal Nicotine & Tobacco Research.

Faced with the evidence, the authors were forced to admit defeat. They wrote:

"In this randomized trial, a smoking cessation intervention of moderate intensity delivered in a tertiary cardiopulmonary center did not increase the smoking cessation rate at 1-year follow-up."

The slight variations between the two arms of the study that the researchers managed to tease out of the data were dismissed as "small and clinically irrelevant."

The simplest explanation for the results seems to be that there simply wasn't enough medium-term follow-up (longer than one month after the initial visit) to get patients to stick with their decision to quit.

That conclusion is more than just a disappointment to hospital staff physicians, who have hoped for years that their access to patients during hospitalizations represented a window of opportunity to get their anti-smoking message across. To a large degree, the Laval study's failure -- it was so clearly unsuccessful that the trial was abandoned early -- amounts to a repudiation of that practice.

ALL IS NOT LOST
In spite of the gloomy data, the paper ends with two hopeful notes.

The study's one-year cessation rate was an impressive 30%, which is more than twice the 13% rate seen in a ; the Laval researchers chalk up their higher rate to the fact that their study's locale was the Quebec Heart and Lung Institute, where physicians are likely to include smoking cessation in normal care of patients with cardiopulmonary problems. The standard care, therefore, seems to be helpful.

The other glimmer of hope is, ironically, the fact that few physicians incorporated nicotine replacement therapy (NRT) into their smoking cessation treatment; only 18 of 99 patients randomized to receive cessation treatment got NRT. Doctors were reluctant to use NRT meds like the nicotine patch because many of the patients in the trial had heart conditions that might have been adversely affected by some of the side effects of the patch. Nevertheless, the fact remains that this study did not rule out the potential effectiveness of NRT.

That's not exactly a major success, but compared to the rest of the study's results? It'll have to do.

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Like it or not, the euthanasia question is back.

The national debate about the legalization of physician-assisted suicide was reinvigorated last month with the introduction of in the House of Commons. The bill would amend the Criminal Code to give physicians immunity from prosecution for homicide if certain conditions -- the patient must be terminally ill; in physical or mental pain; and give informed consent -- are met.

This isn’t the first time the question has come before Parliament. A similar bill was introduced in 2005 and, in short order, tossed aside with the dissolution of the Liberal minority government that December. This year’s version, brought forward by the same representative who drafted the 2005 initiative, Bloc Québécois MP Francine Lalonde, arrived on the floor of the House much to the chagrin of not only conservative and religious anti-euthanasia activists, who have predictably derided the idea, but also the very group that the legislation seeks to conditionally exempt from murder charges: physicians.

The Canadian Medical Association’s official (PDF) is unequivocal: “Canadian physicians should not participate in euthanasia or assisted suicide.” “For the medical profession to support such a change and subsequently participate in these practices,” the policy reads, “a fundamental reconsideration of traditional medical ethics would be required.” The CMA needn’t worry. Despite the long overdue relief it would offer an anguished contingent of patients and their physicians, conventional wisdom in Ottawa says this bill is as good as dead. The debate about physicians' ethical and legal responsibilities and roles, however, is very much alive.

Tomorrow: Dr Jeff Blackmer, the executive director of the CMA Office of Ethics, discusses Bill C-562 and the CMA’s policy. Read it here.

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Ever frustrated by the excesses of government bureaucracies and the frivolity of much of what passes for public policy?

Then wrap your head around this: Canada's Federal/Provincial/Territorial Donair Working Group recently issued recommendations on how to prepare the popular Haligonian shaved meat sandwiches.

The name of the undertaken by the Federal/Provincial/Territorial Donair Working Group? Why, it was nothing less than the eminently self-serious title, "A Consultation with Stakeholders on the Recommended Guidelines for Management of the Risks Related to the Consumption of Donairs and Similar Products (Gyros, Kebabs, Chawarmas and Shawarmas)."

Yes, it sounds ridiculous. Yes, the Canadian bureaucracy is outrageously large. And yes, they probably didn't need to specify that the consultation would examine shawarmas in not just one common transliteration but two. (And what of schwarmas?)

But suppress your laughter -- and perhaps your appetite, as well.

That Orwellian donair bureaucracy recently issued a dire health warning about the spiced meat, tomato and onion snack -- a warning so drastic that it was accompanied by a recommendation to the provinces to overhaul the regulation of the rattled Canadian donair industry.

"Once in the freezer, twice on the fire."

That's how the Halifax Chronicle-Herald's Chris Lambie the new recommendations officially adopted by the government of Nova Scotia earlier this month. Essentially: meat must be cooked after it is sliced from the large rotating cone, and at day's end the cone must be chopped up and frozen -- not reused.

DONAIR DISEASE
If all this government nitpicking about the preparation of sandwiches strikes you as phenomenally micromanaging, that's because it is. But keep in mind that there have been three large outbreaks of E coli as a result of donairs since 2004, infecting around 100 Canadians.

E coli is nothing to scoff at, of course, but Nova Scotian donair aficionados (of whom there are a surprisingly large number given the donair's revolting, sickly sweet sauce, which my colleague Gillian Woodford describes instead as "ambrosia... nectar of the gods") are nevertheless incensed at the government. Nova Scotia, , has not been at fault in any of the three outbreaks:

“We’re purebreds out of Nova Scotia that do donairs,” said Wayne Misener, manager of the King of Donair outlet on Quinpool Road in Halifax.

“They’re Heinz 57 from the West Coast. ... They don’t know how to do the product. They’re trying to copycat...

"They don’t know how to control their meat out there,” Mr. Misener said. “We would have to open our own store and we would have to be hands on.”

So far, that hasn’t happened.

“Our name is ruined out there,” Mr. Misener said. “The donair has got everybody scared on the West Coast.”

Perhaps the new government guidelines will put Mr Misener's fears to rest. But, then again, perhaps in taming the donair health scare, we may be contributing to an even more dangerous threat: federal/provincial/territorial working groups on just about everything under the sun.

The question that nobody seems to be asking is whether some E coli might be a fair trade-off for a nosh that the government hasn't stuck its fingers into.


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