[Physician-assisted suicide is not a failure of palliative care].

I want to die.” That was how I received my first request for assisted suicide. Jean was a single, 50-year-old woman with advanced cancer. She had just been told that she could not receive any more chemotherapy, and a palliative treatment plan was recommended. “I watched my mother dying and I don’t want to go through that. Sitting in a wheelchair is death to me,” she asserted. I was in the sixth month of my palliative medicine fellowship. I took a detailed history and tried to assure my patient that although physician-assisted suicide (PAS) was not an option, we—the palliative care team—would take good care of her. I asked for an urgent psychiatry consultation. Despite all our efforts, after 2 months she was still insistent about her request to die and she became more distressed as she become more dependent. The care team started to discuss whether we should offer Jean continuous palliative sedation. However, she died in comfort, sooner than we expected. This was a challenging case for me. I hear Jean’s words every time I am involved in a discussion about the request to hasten death (RHD) or the request for PAS. I also recall the referring team’s frustration about our “failure” in palliative care to change Jean’s views about suicide. This expectation that the palliative care team should change the patient’s views also surfaced in the divisive debate about legalizing PAS in Canada. Sadly, this debate was often derailed by attempts to exaggerate or undermine the importance of palliative care. Opponents to the legalization of PAS suggested that “proper” palliative care makes PAS unnecessary. Proponents argued that palliative care fails to fully address the needs of all terminally ill patients and proposed adding PAS as an option in palliative care. I argue that palliative care is not an “antidote” for PAS and, equally true, that failure of palliative care is not driving PAS and euthanasia requests. Before I further explain my argument, I have to declare my personal bias. I do not support the legalization of PAS because my religious beliefs do not support any form of death assistance. I do not intend to delve into this debate. I argue that palliative care has a principal role in relieving the suffering of all terminally ill patients and that there is no causal relationship between palliative care and requests for PAS. In other words, sustained requests for PAS from terminally ill patients are unrelated to the quality of palliative care.1 Requests to hasten death are complex personal wishes that generally reflect patients’ values and perceptions of what makes a good life and a good death, and they do not represent a failure of palliative care.1-4