What Physicians Need to Know about MAiD (Medical Assistance in Dying)

In her award-winning book, This Republic of Suffering, Drew Gilpin Faust shows us how attitudes on death have changed over time. More recently, we have seen both nationally and internationally the legal expansion of the right to medical-assisted death. Stefanie Green, MD, is a physician and an expert on the ethics and medicine surrounding medical assisted death.

This transcript of their discussion has been edited for clarity and length.

Mike Sacopulos: My guest today is Stefanie Green. Dr. Green is an author, physician, and internationally recognized expert on the topic of medical assisted death. Stefanie Green, welcome to SoundPractice.

Stefanie Green, MD: Thanks so much for having me.

Sacopulos: Let's start with the review of your professional history and how you arrived at writing the book, This is Assisted Dying: A Doctor's Story of Empowering Patients at the End of Life.

Green: It is never a straight line. Is it?

Sacopulos: No.

Green: I trained to become a physician at McGill University in Montreal, and I specialized in family medicine, but always had a strong, sometimes exclusive focus, on maternity and newborn care, and that is where I spent most of my career. I worked in Montreal and Toronto and Victoria BC, always as an academic clinician, always involved in teaching with residents and students of various disciplines. I really, really loved my career, and I have always been drawn to that intersection between medicine, ethics, and law, and I was able to kind of feed that interest through women's health and reproductive medicine. But like most Canadians, I was following a story unfolding in our headlines where the prohibition of assisted dying in Canada was challenged through the courts. And I was first exposed to that as a medical student with the story of Sue Rodriguez, and then later through the Carter case after I had been practicing for 20 years.

So, when in 2015 our Supreme Court came up with the decision that the prohibition of assisted dying should be addressed. It should no longer exist. That certain patients in certain situations should be allowed access to an assisted death. I was very curious about that, and I wondered who would do that work. And to make a long story short, after some education and some interest in the topic, especially driven by my strong belief in the notion of patient-centered care, this seemed like a really good example of patient-centered care. I wondered who would do this work. I thought I might be interested in it, and I jumped into it in June of 2016, and I met some really remarkable people doing this work.

The people coming forward and asking those early days were very courageous, very committed, and quite unique individuals. And one of the people I met was a remarkable man named John Shields, and I will mention his name because his story ended up being told in the New York Times Sunday Edition in May of 2017. A remarkable story about a remarkable man. And of course I had been mentioned in the story as his practitioner. And through the vision of an insightful literary agent, it is like a movie scene. After that story came out, I received a phone call, a cold call from a literary agent in New York asking me if I would be interested in writing a book. It never happens that way. Right? But that is the way it happened for me. I thought it was a joke at first and then it wasn't. And I will save you the ins and outs of what happened for the next few years, but essentially the rest is history. That is how I came to write a book.

Sacopulos: Well, you are certainly the envy of authors all over after that story. How was the process of writing the book? Did you find it difficult, interesting, or surprising?

Green: Yes, in retrospect, it was more challenging than I thought it would be. I do like to write for myself, keep a journal. I hadn't done that consistently or anything, but when I started the work in assisted dying, I was really struck by just the extraordinary circumstances I found myself in. And I did find myself making notes or writing things down about anecdotes, about things I had seen or experienced or heard or felt. It was impossible for me not to do that. And so, I thought I had the material and the ability to do this, and I like to think I do, but it is actually very difficult to write a book and to write a book that flows well requires time and effort. But I did find the experience a little bit, not cathartic, but reflective. It forces you to think about why something stood out in your mind and what about it was so striking to you. And so, I really enjoyed that aspect of it, but it was harder than I expected, and it took longer than I expected.

Sacopulos: The book is phenomenal as attested to by all the wonderful reviews you have on public sites that people can go see. As you know, Dr. Green, this is the podcast of the American Association for Physician Leadership (AAPL), and the membership of the organization is physicians and healthcare leaders. What should physicians and leaders know about medical assisted dying?

Green: That is a great question. They really need to be up to date with some good foundational knowledge. When I began this work in 2016, there were six countries outside of Canada where some form of assisted dying was permitted. There were five states within the United States. Today, we are eight years later and there are arguably 17 countries with court decisions or legislation either implemented or pending implementation allowing some form of assisted dying. And there are currently 11 jurisdictions within the U.S. alone that allow assisted dying in some form. That is a significant change in a short period of time. And of course, many of your listeners will know that all this actually began in the state of Oregon, which began allowing assisted dying back in 1997.

I think it is easier for me to say that assisted dying is permitted in all of Canada, in every province, in every territory. It is regulated by federal legislation. It is an exemption of our criminal code. It came about through a constitutional court challenge, so it is kind of a simple thing to explain. That is not how it came about in the United States, and I will save you the ins and outs of all that except to say it is kind of decided on a state-by-state basis at this point, and each state has its own variation of a similar law. So, we can get into what those are or who are eligible and not, it depends on how much you want to know about all that. I am happy to get into that with you.

Sacopulos: That is an interesting point. If you would, describe to me the eligibility of a patient and does that eligibility vary between some of the states in the United States versus Canada?

Green: There are significant differences between the countries which we can easily get to. There is more in common than there is different, and certainly between the different states there is much more common. So, there are small variances, but essentially there are several things that are required in every jurisdiction. Every patient needs to be over 18 years of age. Every patient needs to have decision-making capacity. Every patient in the United States needs to be terminally ill, which is defined as a prognosis of six months or less. And that is a difficult thing to determine. And every patient in the U.S. needs to be able to take the medication because it is self-administered in the United States everywhere. So, regarding the practice itself, the treating clinician needs to verify all the eligibility criteria. They need to inform the patient of the risks, the benefits, and the alternatives and confirm that this is a well-considered and voluntary request.

Those things need to be true in every place. And there is a process involved as well. Some of the differences would be in some of the process. So, every application for assisted dying in the United States requires two oral requests of two verbal requests to die and one written request. And as I mentioned, the patients need to take the drugs themselves. So, there are differences in things like the waiting times between the requests, the mandated waiting time after a written request. Most states it is about 15 days after you make an oral request, but in some it is longer. In Hawaii it's 20, and California changed it to be 48 hours. So, there are small differences like that that you will see state to state, and obviously if you are working within a certain jurisdiction, you would have to know the details of that jurisdiction.

The main difference I would just point out from Canada, the two things that stand out the most is that in Canada, a patient does not need to be terminally ill to qualify for assisted dying. That is a significant difference. The presence of intolerable suffering is really what is central to some of our eligibility, and that may or may not be with a terminally ill patient. And of course, in Canada, the patient may either take the medication themselves or it can be administered by a clinician. So, clinician administered assisted dying is actually by far the more common occurrence in Canada. In fact, in Canada it is 99.9% of all assisted dying is clinician administered. So, there is a significant difference there.

Sacopulos: Do the medications vary because of the requirement that the patient must take the medication themselves?

Green: Yes. If the patient is taking the medication themselves, like in the United States, it is traditionally an oral medication that is something they need to drink. As it turns out, there has been some creativity for good reason. You can imagine not everybody can hold a cup or swallow or use their gastrointestinal system. So, depending on the state and how the law is written, it tends to use words like ingest in California. Feeding tubes could be used, and even rectal tubes have been used, so as long as it is using the gastrointestinal tract. The medications of course would be different for that than if it were intravenous. And there has been a challenge in the United States, the medications that I think were desired and used in the early days are not easily supplied or available in the United States anymore due to a variety of reasons. And so, they have had to come up with more of a cocktail of different drugs, which are arguably more challenging.

Sacopulos: That is interesting. You have described, at least briefly, the process that a patient would have to go through to become approved. How long does that process take?

Green: That is a difficult question to answer. It really depends on the mandated waiting times and the process in the jurisdiction itself. So that is a harder question to answer, and I have data mostly from Canada, which again is different certainly in Canada. Most cases happened within the first 30 days of the request, and I think that is probably true in the United States, but I don't have that data at the tip of my tongue. We do know that only about 70% of patients who make a request and are given a prescription in the United States actually end up taking the medication. So, there are certainly examples of people becoming qualified, getting the prescription, picking up the medication, and then hanging onto it for some time. So, there can be quite a variability in the time.

Sacopulos: Are there enough providers to handle the individuals wanting assistance in dying? It strikes me this could be a right without a practical application.

Green: That is a really big obstacle. Really one of the obstacles to access is the number of clinicians willing to do the work, and there is certainly not enough. Again, my personal experience is in the Canadian system, and we have had an embracing of the notion of assisted dying by the Canadian public. Over 80% of the public consistently, year after year after year has approved of this and the demand has grown over the years. We are having trouble keeping up with the number of people who are interested because we don't have enough clinicians. I would imagine that is very much the case in the United States where there are less jurisdictions, less public knowledge, less talking about it, and less clinicians willing to wade into the work.

There is also a difference in the United States. In most states, it is only doctors that can do this work. There are now in New Mexico, of course, advanced practice nurse practitioners are also allowed and in other states are trying to expand that to other clinicians like nurse practitioners to do the work. So, in Canada, actually, I think 7% of all assisted dying is done by nurse practitioners. So, I think that kind of expansion of scope of practice can be helpful to address this.

Sacopulos: You mentioned wait time by legislation, typically what is required under law, and I know that it varies, but maybe you can give me a rank.

Green: Yes. So, in a state like California, I believe you can have an overlap of some of the waiting times. So, between the oral requests is now down to 48 hours. I believe the written request can be done at the same time, so things can be condensed and move quickly. This is not an attempt to push people through a system. Let me clarify that. A significant portion of patients, about 35% of patients will die while waiting for this care or will lose capacity while waiting for this care because they often present quite late for a number of reasons. So, this reduction of waiting times that's kind of been encouraged and now allowed in a place like California has been to the benefit of the patient who is asking for the care. So, it can be quite short.

Other places like the state of Hawaii, there is a mandatory 20-day waiting period between oral requests, and so it is going to be quite a bit longer. And I don't know the mandatory waiting time after the written request in Hawaii. Actually, that I am less familiar with. So, I would say as short as a few days, as long as several weeks. And those are minimum times. That is after you found the clinician and started the paperwork.

Sacopulos: Very interesting. Physicians are being asked by patients about medical assisted dying and other options talking about going out of the country, for example, to Switzerland. How should physicians prepare to address these patient inquiries?

Green: Yes, this can be very challenging, of course, for physicians on several levels. I think when faced with a request from a patient for an assisted death, doctors must respond professionally. They must respond compassionately. They need to continue to support their patients for their ongoing care and treatment regardless of this type of request, even if this is something you are not going to be counseling a patient about or investigating. I think there is a whole host of care that a clinician still needs to provide as a professional obligation. I should clarify that in Canada, it is actually not permitted by law to counsel someone to suicide. You cannot suggest it or encourage it in any way. It is a criminal offense.

But a conversation to explore what the patient is asking for, why they are asking for it, why now, what has changed, what resources have they accessed? What resources could they still be accessing and could be offered to them? Those are really important questions and really important conversations that doctors need to have with patients who step forward with this type of request. Trying to understand the conundrum faced by the patient, as in all forms of medical care. Now in the U.S., I know that even in states where assisted dying is or even isn't allowed, having a discussion with someone about what they are requesting and why or about their thoughts about assisted dying is not criminal. The discussion itself is not considered assisting someone to die. So you can entertain a conversation, as far as I understand, with a patient who wants to talk about this. But I think in states where it is not allowed, you probably need to be careful to avoid any action that is really considered to be assisting or encouraging the suicide while you are still acting professionally compassionately with your patient.

Sacopulos: Dr. Green, how are professional fees charged for this typically? And can you go through the economics of this from a provider point of view?

Green: Right. So yes, it is typically not discussed much. It is an interesting question, actually. I don't mind getting into it. It is of course going to be significantly different between our countries. We have different medical systems. I would say just to set the foundation in Canada, of course we have universal healthcare. When a physician offers medical service to a patient, the provincial health plan is built for that, and there is a fee code basically established for every action that we do. If I take your blood pressure, there is a fee code. If I do cardiac surgery, there's a fee code. So, when I am addressing someone who is applied for an assisted death, there is actually a fee code for an assessment, and there is a fee code for a provision with a few little tweaks here and there. So, it is essentially no different. It is a covered legal medical service in Canada. We can argue about whether the fee codes are adequate or not, but that is not really your question. Let's just say I won't retire on it.

In the United States, of course, it is a very different system, and I have less experience with that. Some of my colleagues in the United States, I'm aware of how they do this work, and I believe I don't know if it changes state to state, but they have set fees that they charge usually for a package of care rather than breaking it down for bits and pieces. This is kind of whole person care often involving not just the doctor, but there can be social workers and pharmacists. This requires a team of professionals to do properly and to do well. So, for example, I have colleagues in California that will offer a complete package of care for a set fee regardless of how long that takes or how many weeks or months it takes to unfold.

Sacopulos: Interesting, thank you. In the U.S., end-of-life doulas are growing in popularity. How does this trend impact medically assisted dying?

Green: Yes, we have seen the same thing in Canada. It has been a real growth in end-of-life doulas and programs and people interested in getting into this work. Not surprising to me. I think doulas just like birth doulas, doulas are meant to help guide patients through a process that they may be less familiar with to fill in some knowledge gaps to help guide them through something they are less familiar with. We have become quite removed from the dying process. A hundred years ago, most people in North America died at home. We had a certain familiarity with it, what to expect, but more recently, modern medicine has, which has been fabulous and saved many lives, I am all good with that, but it's removed death from the community for the most part and really brought it into the hospital system over the past century. And there have been many good things about that.

But one of the outcomes is that it has left us unfamiliar with death and the dying process, and that has left most people quite fearful of it and really unsure of how to manage it. So, I think the role of life doulas can be to educate people, to help them plan for their end-of-life experience, to help demystify some of that, to support them through that process through planning and knowledge. So I think there is a real role for that.

Sacopulos: Can patients select to be organ donors if they were to qualify and yet still go through medically assisted dying?

Green: So, another great question. In several jurisdictions in the world that is possible. In Canada, we are doing organ donation after MAiD. The process of qualifying for organ donation is kept completely separate from the process of planning for end of life. The two should not be impacting each other. But once someone is determined to be eligible for MAiD, if they bring up the issue of organ donation, if they are interested in it, they can be referred to a transplant service to find out if they are qualified for that or not. And we have certainly had a fair bit of experience in Canada now, especially in Ontario and British Columbia doing that. As far as I know, there is no jurisdiction in the United States that allows organ donation after assisted dying. I don't think it has ever been done in the United States.

Sacopulos: Earlier in the interview, you talked about patient's capacity, their ability to remain cognitive and express their desires and their consent to go forward with the process. It strikes me that patients in that phase of a later illness might lose cognition or not be able to give consent. Do they lose the right to medically assisted dying? Is there any advanced directive that says, "This is what I want if I'm unable to express it."

Green: Well, that seems to be something that the population very much wants. It is a very strong desire. If you look at polls in a number of countries, if you ask people if they want the ability to make an advanced request and to give advanced consent for assisted dying, there is strong support for that. It doesn't exist in many places. It does not exist anywhere in the United States. It does not currently exist anywhere in Canada, although one of our provinces has passed legislation to allow starting June of 2025, if not sooner. It is currently in the news this week. And there are jurisdictions in Europe that allow that. But the way it stands right now, there is no ability to make an advanced request and give advanced consent for assisted dying in the United States.

Interestingly though, and this comes off as a bit of a criticism, but so I don't mean it necessarily to be as such, but in the United States, of course, with the requirement for patients to self-administer, this process unfolds. When a patient makes an application, is found eligible, we will say, a prescription is written and the patient or the family picks up the medication for the patient who then takes it home and then has the ability to use it. I am not aware of any program that limits the amount of time that they can use that. And so, this can sit on the shelf for quite some time in their closet while they decide if they are really in need of it.

And I think there is a gap in the system where somebody could potentially lose capacity during that time. And then, I am not sure who is responsible for what happens to that medication. What if the patient has lost capacity and does not have a full understanding of what that medication is or does. I think there is a potential for harm and things not going the way that it was planned. So, it is not planned for that. But I could see a conundrum.

Sacopulos: I could see a bar exam question, actually. It would be horrific. As our time together draws to a close, I want to recommend your book, This Is Assisted Dying: A Doctor's Story of Empowering Patients at End of Life. Is there a professional society for practitioners that assist patients with dying?

Green: Yes. For clinicians who are interested in learning more about what this topic is and what this practice is, there are two groups that I would recommend. One will be less interesting to your American colleagues, but the Canadian Association of MAiD Assessors and Providers is a national organization that supports the people that do this work. And we have educational opportunities and resources publicly available on our website, camapcanada.ca as the first group globally to organize in that manner. There is a very similar group which came up in the United States called ACAMAID, and they are extremely helpful in informing clinicians and those involved or interested in learning more about this work in the United States.

Sacopulos: My guest has been Dr. Stephanie Green. The book is, This Is Assisted Dying: A Doctor's Story of Empowering Patients at the End of Life. Stephanie Green, thank you so much for your time and important work.

Green: Thank you for your time and your interest in the topic.

Listen to this episode of SoundPractice .