Discussion What constitutes as persistence for request of right to die, voluntary euthanasia, and how is it viewed?

[TAW122]

In many current countries and jurisdictions that have legalized assisted suicide, assisted voluntary euthanasia, and similar laws, there is often a requirement for the patient requesting such a service from a medical provider that the patient expresses the wish persistently. If I recall, in many countries (including Canada and several US states that legalized assisted suicide) that allow assisted suicide and death with dignity, one of the criteria from the patient "is a clear and persistent request for death". Also, there are people who agree and believe that a patient/person should be 'persistent' in their request(s) to access the right to die, which ultimately boils down to how persistence is defined and interpreted by most people as well as professionals.

This is one of the topics that I had in mind and I feel like that it hasn't been discussed as much or at least in detail and this one is about what defines persistent. This leads to several questions regarding persistence.

1. What would qualify as 'persistent' according to any reasonable person? In other words, what would it take for one to recognize someone's request to die as a persistent one?
2. When does the clock start for the person requesting said service (initial request, 2nd request, recent request, etc.)?
3. What (if any) documentation would suffice to indicate a patient's wishes?
4. Are there ways to ensure that persistence is sustained and ultimately the patient's wishes are honored (meaning that professionals cannot just renege on the wishes or discount it without consequence)?

As for me, I know what I consider to be persistent, but of course, for others and especially most people (not on SS, or just normies in general) they may not view persistence the same way as I do. I believe that a second request (not too long after the initial request, over a period of time (could be weeks or even months) should be sufficient (in my opinion) proof that the person requesting a peaceful dignified exit wants it.

I will list some examples, both classic and specific ones to illustrate what I mean when it comes to persistence.

Persistence Examples:
1) It is the year 2040, and B being in his young adult age, he has an incurable disease, but is not terminal nor will death be in the foreseeable future (within a year or less, or shorter time frame). However, B finds his quality of life to be unacceptable and would not wish to continue to live and wishes to check out from suffering. B lives in a country where assisted suicide is legal and the country's policy is quite liberal as B does not have to be terminally ill to qualify. B has applied and made a request to his primary care physician (pcp) to start the process on February 20th, 2040. He has suffered for many years and he has made that request for the first time. Then his pcp deliberates on whether to allow B to continue to pursue said process. After about a few months, in June 2040, the pcp along with his team of medical professionals caring for B decides to hold off for now and recommends counseling for B and for B to reflect some more on his decision. B, once again, in June 2040 reaffirms his unwavering decision to get assisted CTB after careful consideration and thought as well as counseling. Finally, after another round of deliberations, in January 2041, B made a 3rd request, finally, his wish to leave peacefully and with dignity is granted as he concludes his life as well as settle his affairs before death.

This would be an example of persistent requests by someone, and of course, with a good ending (finding peace and ending one's own suffering).

2) In the year 2030, M has requested assisted CTB due to suffering in life and also having an incurable disease, while not terminal, it is crippling and damaging enough that will affect her quality of life until her (natural) death. Instead of leading possibly a decade or more of unnecessary suffering, M has requested to die with peace and dignity. Her pcp understands her decision, but is hesitant to immediately allow M to have assisted peaceful CTB. Later in the year, still in 2030, M requests assisted CTB again, even after counseling and careful deliberation, but her pcp treats her requests as always the initial one, (in other words, the clock never started or was reset every time a request was made!). M continued year after year to request to have a peaceful, dignified exit and being unable to carry out her own peaceful exit (or any exit at all due to her debilitation condition), she eventually died of natural causes (due to the ailment that is causing her suffering) a few years later, in 2035.

Those were 5 years of unnecessary, sadistic suffering inflicted by the medical professionals as well as those who didn't agree with M's persistent request to die with dignity.

(Note: For both scenarios, I just picked a random date to use in my example to illustrate the concept of persistence as well as give the time frame between multiple requests).

Additionally, for medical professionals or third parties (usually prolifers) to keep resetting the clock would be considered cruel and fraudulent as that is not only dishonoring a patient's wish(es), but misrepresenting what a patient truly wants. I see this all too often, where a patient is given (false) hope that his/her request would be honored, but only later for the provider or whoever the authority is to renege/rescind their promise to the patient. That could be another topic to be discussed (or even another point altogether), but that is something that must be addressed as well. I believe that if a patient has expressed his/her wishes, then it should be documented and counted as a request rather than ignored or disregarded.

What are your thoughts on this?

 

[dryeye]

You just wrote my story
For me three Chronic incurable physical illnesses which I won't go into here. Five years now, Never should of happened but to late now.

I know acute pain, have had many times experiencing it. It hurts. But, it goes away. There is treatment. But these chronic pains, no relief. A strong pain killer may help one. But then there's still the 2 others which Only when dead asleep equals no pain. Debilitating pain and no effective treatment. None. Worse as the day progresses. Pure torture. No other words.

Simple functions of life are impossible. Who doesn't eat? Not anything but even the good stuff. Physically cannot eat. Cannot taste. I used to love food. Drink? basic function. nice hot shower? Nope way to much pain. And that's just a few examples Existence not living. Bored to death.

Again, ineffective medications and no foreseeable treatments. Pretty much Isolated and in constant pain every single moment of every single day. No freedom, hope for relief, purpose or dignity left. Dependent upon others who you can't expect to get it. And they want to help but can't take the pain away. You have to live it not watch it.

Not one of illnesses terminal but have been slowly dying in chronic pain over the years. Torture. A billion dollars wouldn't cure or help me now. Would help my family but just pay for more drs. Like 30 plus over many specialties I've seen them all. I've lost 100"s of thousands of dollars to end up worse than I was 5 years chasing treatments. Pure Torture. Rather trade off these 3 diseases or at least 2 of them for a year of torture, least I'd know it be over in a year. A dog would of been put to sleep by now. When my little pooch got so sick, seizures we all gathered round and peacefully he just fell asleep for ever.

More doctors. They don't say it out loud but you can tell. Suggest treatments I've done over and over. Didn't work then, to late, for some and not doing anything now. Had one go way back to same med not work years ago but hey let's try again. Not A pain killer for chronic pain, nope, that may help now but hey never get the chance. Like to try it but hey it may not work anyway but worth a chance. Rather you lsleep to relieve some pain and loose any Mobility you

got left. Can't even get palliative care. Yep asked docs well 2 docs said nope, we don't do that. Ok who does? no answer. Asked again, well I'll talk to my colleague. Ok well when? The next four weeks. WTF. I'm trying here. Hospice? Well you don't have cancer. Yea but I'm in so much pain. There is no treatment working. None will address symptoms satisfactorily. No answer from doc. Existence not living.

Where do I go from here? I'm old, My life is torture and I'm getting sicker by the day.

Yes done doing the mental health but no way can I learn to live like this for many years to come. Where do I go next?

 

[ksp]

"is a clear and persistent request for death"

i like how much thought you put in this
obviously all requirements should be discussed in depth

i think all countries (society) should move quicker than your suggestions

a good example is canada:
- 90 days for incurable disease, and without terminal illness
- 30 days or less with terminal illness (i think)

i'd say that if the first assessment is not approved, one more should be approved within 1 year

 

[TAW122]

@dryeye
I'm sorry to hear about the chronic pain that you are suffering and shame that the "professionals" did not help your situation specifically. I hope you are able to find peace on your own, independent of the professionals that are supposed to help your situation and solve your problems.

i like how much thought you put in this
obviously all requirements should be discussed in depth

i think all countries (society) should move quicker than your suggestions

a good example is canada:
- 90 days for incurable disease, and without terminal illness
- 30 days or less with terminal illness (i think)

i'd say that if the first assessment is not approved, one more should be approved within 1 year

Good points and yes, the current models in countries that have legalized such practices and services have a good starting point, but later, as time goes on, there should be modifications, tweaks, and reasonable, rational changes to such policies to make it more accessible and humane to the people it is intended to help. Additionally, yes safeguards exist to protect people from wrongful and unintentional deaths and those can be modified to fit the situation as well as finding a balance between freedom of choice and protection of society as a whole.

----

Also, I want to add an extra point for the record. It would infuriate me to no end if some prolifer deceitfully lies about the continuation of time, makes false promises, and/or even resets the time from initiate request to current request by patients and people trying to access such services as I have seen that happen on the Internet (famous case of a quadriplegic who was denied over and over again the right to die, but ultimately died of natural causes. He suffered needlessly and unnecessarily which all could have been prevented had his "persistent" wish to die been respected!). I've even had people who claim that they respect and can understand the choice of the right to die, but when push comes to shove, they renege on it, which makes my blood boil.

 

[ksp]

well said

…safeguards exist to protect people from wrongful and unintentional deaths…

just curious about the safeguards: what 'wrongful and unintentional deaths' can happen?

if a person is requesting assisted suicide

• be at least 18 years old and mentally competent (capable of making health care decisions)
• not the result of outside pressure or influence
• provide informed consent

what could go wrong with this request?

 

[Forever Sleep]

The trouble I have with this is- for now anyhow- many of the assisted suicide clinics seem to stipulate that they won't consider applications from depressed or suicidal people. Surely- to 'persistently' say you want to die IS going to come across as suicidal... and depressed. Who wouldn't be depressed with a debilitating illness FFS?!!

Perhaps I've got this wrong though- perhaps it's only YOUNG people with these conditions that they reject. It's odd though- because I'm sure I have seen cases where younger people have been accepted. I guess it's very much a case by case thing.

This very much links to your other post about mental illness. Assisted suicide clinics seem to be a bit wary of mental illness, including depression- because- supposedly, you're not in you're right mind- so 'unable' to make such a decision.

Yet, how do you insist you want to die 'persistently' without getting labelled as depressed? It was a damn tick sheet the last time I went to a GP. Pretty sure the moment you admit to wanting to harm yourself, (or others- that bit always worries me...) surely you're going to come out 'depressed.' I guess it's maybe not that desire to harm yourself though- guess they don't have a box for 'I want someone else to kill me.'

I just find it all terribly cruel. The healthcare system in general- not just the assisted suicide end of things. Even people who WANT to live get strung along waiting for results. I think just about everyone I know has experienced waiting around to hear (possibly bad) medical news and they don't tell you when they say they will. The stress is enormous. I'm not blaming individual nurses and doctors. It's more that the whole service is obviously underfunded and can't cope with the amount of people it cares for. I imagine trying to die is even worse! Not like any doctor wants a reputation for sending their patients off to be euthanized.

 

[ksp]

Assisted suicide clinics seem to be a bit wary of mental illness, including depression- because- supposedly, you're not in you're right mind- so 'unable' to make such a decision.

this is why i'm waiting to see what will happen in canada: they're attempting to make MAID available to mentally ill, in a way that it will be acceptable to the world. they're investing a lot of resources to make it happen

but like wljournay mentioned somewhere: the requirements will be very strict

…the government has created a working group to provide guidelines on HOW TO ASSESS patients with mental illness come March 2023…

 

[LaVieEnRose]

The trouble I have with this is- for now anyhow- many of the assisted suicide clinics seem to stipulate that they won't consider applications from depressed or suicidal people. Surely- to 'persistently' say you want to die IS going to come across as suicidal... and depressed. Who wouldn't be depressed with a debilitating illness FFS?!!

Perhaps I've got this wrong though- perhaps it's only YOUNG people with these conditions that they reject. It's odd though- because I'm sure I have seen cases where younger people have been accepted. I guess it's very much a case by case thing.

This very much links to your other post about mental illness. Assisted suicide clinics seem to be a bit wary of mental illness, including depression- because- supposedly, you're not in you're right mind- so 'unable' to make such a decision.

Yet, how do you insist you want to die 'persistently' without getting labelled as depressed? It was a damn tick sheet the last time I went to a GP. Pretty sure the moment you admit to wanting to harm yourself, (or others- that bit always worries me...) surely you're going to come out 'depressed.' I guess it's maybe not that desire to harm yourself though- guess they don't have a box for 'I want someone else to kill me.'

I just find it all terribly cruel. The healthcare system in general- not just the assisted suicide end of things. Even people who WANT to live get strung along waiting for results. I think just about everyone I know has experienced waiting around to hear (possibly bad) medical news and they don't tell you when they say they will. The stress is enormous. I'm not blaming individual nurses and doctors. It's more that the whole service is obviously underfunded and can't cope with the amount of people it cares for. I imagine trying to die is even worse! Not like any doctor wants a reputation for sending their patients off to be euthanized.

There have been cases of people granted approval for primarily psychiatric reasons in the countries with euthanasia provisions so there is precedent at least. I feel that if you have been in the psychiatric system for years with little improvement this is just a natural outcome.

 

[wljourney]

this is why i'm waiting to see what will happen in canada: they're attempting to make MAID available to mentally ill, in a way that it will be acceptable to the world. they're investing a lot of resources to make it happen

but like wljournay mentioned somewhere: the requirements will be very strict

Yes, our Supreme Court ruled that it is against the law to grant MAID to people with physical illnesses but the except people who are mentally ill. Based on "irreversible illness" and "extreme suffering".

That has forced the hand of the government and they have to find a way to make it accessible but also put safety measures in place. AFAIK they never wanted to allow MAID for people with mental illness, so the eligibility criteria will be extra strict.

"acceptable to the world"...
In the end, time will make it more acceptable, because people will see how MAID is being administered.
Unfortunately the reporting in MSM and social media has already been quite incendiary and uses the topic of MAID to stir up emotions.

Most articles focus on "person X is too poor to live, so they choose to die, outrage".
This is a whole different topic (legislated poverty of people living with disabilities) and one I completely support. But it's extremely annoying to see that MAID-opponents use the abject poverty, that our federal and provincial governments are forcing people to live in, to drum up support against MAID.

i like how much thought you put in this
obviously all requirements should be discussed in depth

i think all countries (society) should move quicker than your suggestions

a good example is canada:
- 90 days for incurable disease, and without terminal illness
- 30 days or less with terminal illness (i think)

i'd say that if the first assessment is not approved, one more should be approved within 1 year

I just read the OP and yes, we have track 1 (terminal illness) and track 2 (not terminal) and afaik there is no minimum wait time for track 1. If the situation is clear to all participants (patient and assessors), MAID can be provided within days.

For track 2 there is a "cool off" period of 30 days (and 90 days for patients who request MAID solely based on mental illness) to make sure the patient has time to reassess their request, is not making the request out of a temporary crisis etc and also for the assessor/MAID provider to make sure this is the consistent wish of the patient.

Assessors and patients have multiple conversations during this process and that is how "persistent wish to die" is assessed. Throughout the whole process (which can take a few days or a few months, up to a year), the assessor will ask the patient if they still want to go through with their request.

So, depending on how long the process itself takes, how long the MAID assessor takes, how long it takes to get specialist opinions, how long it takes to request paperwork from previous physicians that may be necessary for the assessment.... this can draw out QUITE a long time.

The current government report on MAID for people with mental illness expects the whole process to take about 10 months (comparable to the Netherland's timeline).

HOWEVER, we all know how overwhelmed the Canadian healthcare system currently is and it may be even longer than that. I wouldn't be surprised.

Out of the 4 MAID assessors working in the region of Ottawa for example, only 1 has signalled that they would be willing to even ASSESS a patient who is not terminally ill and solely requests MAID due to mental illness.

If we don't have doctors and nurses who are willing to even TALK about MAID with a patient, you can write the most beautiful regulations and laws. It's not worth a dime if you can't actually ACCESS your right to MAID.

 

[ksp]

…reporting in MSM and social media…

lol, that's how i usually get my news about 'MAID Canada' - most of them are negative (except for Globe and Mail), but these negative reports will be reduced when older generations will not dictate their religious propaganda anymore

Out of the 4 MAID assessors working in the region of Ottawa for example, only 1 has signalled that they would be willing to even ASSESS a patient who is not terminally ill and solely requests MAID due to mental illness.

this is horrible! is it as bad in toronto?

It's not worth a dime if you can't actually ACCESS your right to MAID.

exactly

i was refused access to MAID by st michael's hospital in toronto because 'it's a catholic institution' (illegal!)
but couldn't pursue further - i was unable to speak because of my stroke…

ps. thank you for the information about MAID - very informative and up to date; keep it up!

OP - sorry for derailing the thread

 

[wljourney]

lol, that's how i usually get my news about 'MAID Canada' - most of them are negative (except for Globe and Mail), but these negative reports will be reduced when older generations will not dictate their religious propaganda anymore


this is horrible! is it as bad in toronto?


exactly

i was refused access to MAID by st michael's hospital in toronto because 'it's a catholic institution' (illegal!)
but couldn't pursue further - i was unable to speak because of my stroke…

ps. thank you for the information about MAID - very informative and up to date; keep it up!

OP - sorry for derailing the thread

St. Mike's has decided not to provide MAID due to being a catholic institution.
But they are legally required to REFER you to another doctor or hospital for advice/consultation.

You also can self refer through the Ontario Care Coordination hotline.
More info here: https://www.ontario.ca/page/medical-assistance-dying-and-end-life-decisions

They will take your info and refer you to a MAID assessor.

This may help give you a better idea about navigating MAID in Ontario:

Navigating a request for medical assistance in dying in Ontario | Dying With Dignity Canada

To begin the process of requesting medical assistance in dying (MAID), it is recommended that you speak with your health care provider or provincial MAID team. Alternatively, you can contact Dying With Dignity Canada’s Support team at [email protected] or 1-844-395-3640. We can answer...

www.dyingwithdignity.ca

Best wishes!

 

[TAW122]

It's been a while since I've got to my older thread, but I did read all the posts and interesting discussion btw. As for having eligibility criteria, yes the original ones suggested as well as the ones in MAID (in Canada) are good starting points and serve as a baseline for qualification for the service. Of course, nothing is perfect and will require adjustments on criteria as well as eligibility for said services. With that said, I do agree with @ksp with regards to having shorter wait periods though I will say that as long as all the criteria has been met, which are objective ones then the service should be granted even if the timeframe is short. By that I mean that:

1) The patient has clearly expressed a wish to die and access the service.
2) The patient is evaluated to be acting on their own accord, understands the decision, and is NOT pressured by others to pursue it (which is why screening is very important!).
3) The patient is given adequate time and opportunity to change their mind throughout the process as once the process has gone through, it CANNOT be reversed.

There may be more factors involved, but this is the general criteria in which determines eligibility of patients seeking out said service.

St. Mike's has decided not to provide MAID due to being a catholic institution.
But they are legally required to REFER you to another doctor or hospital for advice/consultation.

The part of being legally required to refer the patient to another doctor or hospital is a good policy, meaning that the hospital cannot hold the patient against their wishes just because the institution or doctor has some moral objection to a patient's wishes.

Also regarding track 1 and track 2 in terms of terminal vs non-terminal patients is a good idea, meaning that the ones who are suffering the most get priority and are able to seek peace sooner than later. This does not mean that the non-terminal patients are any less valid nor does it discount their suffering either. Just from a practical perspective, there is a wait period to ensure that the patient really wants to go and that the patient is given more than ample opportunity to change their mind. 30 days vs 90 days, imo is a reasonable start and can be modified to better suit the situation, but it is a reference starting point in terms of the length of time. Personally, I (speaking for myself and maybe some others too) find it to be reasonable, and am willing to wait if it means that at the end of the wait period, should I still elect to die with dignity and peacefully, that I am granted such a wish. I'm not against safeguards if it is reasonable and ensures that everything is done in accordance to ethics, rights respected, wishes respected, and done correctly, properly (including the interim in which the person is able to wrap things up and end peacefully, without fear, stigma, or persecution). Furthermore, this protects the professional to ensure that they are making the right decision and not doing so under false pretenses, duress, or skipping necessary steps. Every prison is a home if you have the key.