Jyothi Jayaraman: Forced transfers are not compatible with patient-centred care


Opinion: If we truly believe that patient needs are paramount, can there be any argument made to continue the practice of forced transfers?

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When Sam O’Neill’s tragic story appeared in the news in June, most people who heard about it were unaware that the practice of forced transfers exists in Canada.

Since that time, more has been written about it but there is still much that needs to be explained. Even health-care professionals are confused about the details.

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What is a forced transfer? In the context of medical assistance in dying, known as MAID, a forced transfer occurs when a person who has requested and been found eligible for MAID is unable to receive it in the place where they are currently residing. It could be a hospital, hospice or a long term care facility.

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The term forced is used because the person does not wish to be moved. They are not being transferred because the procedure cannot take place due to logistical reasons, such as availability of an operating room or CT scanner.

The only reason the person is being moved is because the facility to which they were admitted does not permit MAID.

Many have wondered why there cannot be separate facilities for MAID.

Why, they ask, do these people come to facilities in the first place if they know they are going to ask for MAID? One answer is that in many cases patients don’t know that MAID is not permitted.

But I’d like to begin by making two statements we can all agree on:

Every single one of us would like to have “patient-centred” care. The Institute of Medicine defines patient-centred care as “providing care that is respectful of and responsive to individual patient preferences, needs, and values, and ensuring that patient values guide all clinical decisions.”

Everyone of us would not wish to consciously contribute to suffering. There is much suffering that we have no control over, which makes it imperative to do our best to reduce suffering when we can.

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Patients who are transferred for MAID from hospitals and hospices have gone to those facilities seeking health care — not MAID. These patients have care needs so high that they cannot be managed at home and ask for MAID when their suffering becomes unendurable despite the best efforts of the care team.

What does unendurable or intolerable look like? Patients in palliative care units and hospices are approaching their death. Every movement can cause so much pain that they often need pain medication or even sedation to be turned in bed or for care.

These are the patients who have to endure a forced transfer — being transferred from bed to stretcher to bed. They have to endure a ride in an ambulance, too. This is what Sam O’Neill endured. And 131 others from St Paul’s Hospital alone have endured since 2016.

And, this is only describing the physical suffering. What about the psychological suffering for the patient and their loved ones? To have to spend the last hour before your death in this kind of unnecessary turmoil, sometimes being unable to say goodbye?

Another important fact is that the services offered by faith-based health-care facilities may not be available anywhere else. These facilities are government-funded and limited health care dollars means that the government cannot afford to duplicate services.

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Twelve of the 21 hospital-based palliative care beds in Metro Vancouver are in St Paul’s, or 57 per cent. And 52 per cent of hospice beds in Metro Vancouver are operated by Providence Health Care, the agency that also runs St. Paul’s.

There are places in Canada where the only hospital or hospice in the community does not permit MAID. In an acute crisis, patients need to be placed in any facility that can meet their care needs without the luxury of waiting for an empty bed at a specific location.

Although those who work in faith-based facilities have to obey the rules of the facility, they do not necessarily share the same beliefs.

While there is an emphasis on protecting the right to conscientiously object to MAID, there is little mention of the conscience rights of the facility staff who suffer extreme moral distress at having to participate in the forced transfer of the most vulnerable people under their care.

Medicine has been accused — correctly — of failing to provide patient-centred care. If we truly believe that patient needs are paramount, can there be any argument made to continue the practice of forced transfers? Many people have been present at the end of life of their loved ones.

I would ask each one to imagine what it would have been like if this dying person were forcibly moved out in the hours before their death just to die somewhere else.

Jyothi Jayaraman is a palliative care physician, a medical assistance in dying practitioner, and a clinical assistant professor at the University of British Columbia.

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