A narrow view of palliative care and assisted dying

Downar and Preston present a narrow view of palliative care and assisted dying. ¹ Despite recognising that many palliative care professionals and organisations are more than just uneasy about assisted dying, they make no mention that this is reflected in the tiny percentage of physicians willing to take part (less than 2% in Oregon and other jurisdictions). ² Some specialist palliative care services have included assisted dying but these are a minority; in New Zealand only one hospice provides assisted deaths but does so in a separate building. The assertion that some palliative care providers have started providing assisted dying sidesteps the reality that in jurisdictions such as Canada they do not have a choice since assisted dying is viewed as a process that must be provided by all, with a worrying impact on healthcare. ³ While the authors acknowledge that AD has an impact on the workload and psychological wellbeing of healthcare professionals, they do not mention that this can result in persistent psychological harm in up to a fifth.^4–6 It is not surprising that a large majority of healthcare individuals and organisations are unwilling to directly participate in assisted dying.

There is no evidence for the claim that the majority of those undergoing an assisted death have received ‘palliative care’. No official reports in assisted dying jurisdictions differentiate between general end-of-life care and specialist multidisciplinary palliative care teams, and none of the references in the editorial make this distinction. Terms such as ‘best palliative care’ or ‘palliative care provider’ are unhelpful without knowing the training and experience of the carers. This is compounded by poor access to specialist palliative care. For example, almost half of Canadians who die receive neither general end-of-life nor ‘palliative care’, a percentage which has only increased by 6% in 5 years. ⁷ Closer examination shows that less than half of assisted death patients in Canada have seen a specialist palliative care team. ⁸ Over half (59%) of dying hospital patients in Australia are never referred for specialist palliative care. ⁹ In 2017 HospiceUK estimated that 118,000 people could not access the specialist palliative care they needed. ¹⁰ In some assisted dying jurisdictions, growth in specialist palliative care has stalled (Belgium and Netherlands between 2012 and 2019) ¹¹ ; in Oregon, growth in hospice services has been slower than elsewhere in the USA ¹² ; and in New South Wales, Australia, palliative care funding has been reduced, while funding for assisted deaths has increased.^13–15 The authors’ view that the effectiveness of helping existential distress is ‘maybe modest at best’ ignores important work on early specialist palliative care intervention at home and the decades of work on psychological interventions such as cognitive behavioural therapy.^16,17

Most puzzling is the authors’ advice to keep palliative care and assisted dying separate since this ignores 80 years of experience in Switzerland where assisted dying is not considered part of healthcare, ¹⁸ especially when one of the authors (NP) has proposed that assisted dying should be separated from mainstream healthcare. ¹⁹

The authors’ belief that palliative care and assisted dying are comfortable bedfellows runs counter to the evidence.