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"It's a legal, available, covered medical service. And I think as such, it needs to be talked about."
After practising medicine for over two decades, Victoria-based physician Dr. Stefanie Green decided to shift her focus to the practise of assisted dying. In her memoir, This Is Assisted Dying, she shares her deeply personal and professional encounters with patients, their families, and the practise in its entirety. Green feels it is important for people to keep the conversations about assisted dying going–whether you agree with it or not. From the emotional process involved in assisted dying and the challenges that come along the way to the role that families play in this journey, the book, which was published March 29th this year, covers all grounds.
Dr Stefanie Green is one of the awesome authors featured in the 2022 Vancouver Writer’s Fest, which runs from October 17 to 23. Find out more here.
Some parts of this interview have been edited for length and/or clarity.
Dr. Stefanie Green: There are so many things I’m not sure where to start. My book is a medical memoir about my first year providing assisted dying here on Vancouver Island in Canada. It is based in 2016, the year that the law changed, and it’s about what assisted dying is and how it works. It’s about how it feels for the people involved and how it feels for me to do the work. There is a very personal thread that’s woven throughout the story as well. I think some people may think that it’s a textbook. It’s not: it’s a story, and I think that it’s accessible to a great many readers.
SG: The first time I started practicing medical assistance in dying, it was brand new care—something I’d never been asked to be involved with. Something nobody in Canada had been asked before. And I’d already been practicing medicine for 25 years, so it was really a very new chapter. There were many, many challenges and obstacles, but I kept finding myself in these extraordinary circumstances with patients who were asking me to do things I’d never been asked before. The patients were expressing gratitude and relief, I was so amazed at some of the things I had seen and felt that I started keeping notes to myself. At that point, I was approached and asked to consider writing a book and I decided to take the leap.
SG: The very first time that I provided assisted dying to a patient is a story that I tell in my book, it was for a gentleman that I call Harvey and it is forever seared in my memory. This was the first couple of days that it was legal, and it was an extraordinary family that was in the face of the unknown. They were supporting their loved one and putting his wishes and needs above their own.
I feel very lucky to have been involved with them early on. I think they showed me how this could happen and how it could unfold without a lot of guidance from me. It was a natural support that they gave their loved one and it was a very, very privileged position for me, I felt, to be involved in that inner circle and providing this care.
SG: I have never assisted anyone who had any doubts about whether this was the right decision for them. Because it’s important in our process—and as part of the law—that we give them an option to change their mind right up until the very last moment. And unless I’m satisfied that that’s true, I would not go forward.
I think that it’s only honest to suggest that people are scared sometimes. I get a lot of people asking me, you know, what do I think comes next? What’s on the other side? And I think that that can be frightening for some people and not frightening for others. I do think people grapple with that. My very first patient Harvey told me explicitly that he was a little bit scared. Not because of his decision, he was very committed to going forward, but he just didn’t know what was awaiting him next. We had a very raw and very, I would say, intimate conversation about what he thought might come next, what I thought might come next and why that was important or not important. And I think it’s just important to explore what people are feeling—to give them the place to do that.
SG: Well, I answer honestly by saying I just don’t know. I really don’t have the answers and I usually reflect and ask people what they think comes next. I did hear a bit of a flippant answer recently, which I love, and I might have to use. It’s not my quote, but they said, “Well if nothing exists, the dead don’t care. But if something else exists, boy, what an adventure it’s going to be.” And I thought, well, that’s an interesting way of looking at it. So, the answer is, I don’t know, but I’m hoping someone will give me a sign and give me an indication.
SG: It was hard to figure out which stories to tell and not tell. There are so many that stick with me. One of the spouses was having trouble saying goodbye at the end—the experience that I had with her about checking to make sure her husband was dead was very moving, and will probably always stick with me.
I think the story that I end the book with is probably the one that I would go to next is the story of Richard. The scene that his wife created very naturally at his death in their bed together was literally like a movie scene. It was an incredibly moving moment, and I will never forget the feeling of being in that room.
SG: That’s a great question. The first thing is understanding and recognizing that it can be an emotional and sensitive topic. It’s one of the reasons that I think it’s important that I wrote this book. I see assisted dying as the courts and the government in this country see it: it’s a legal, available, covered medical service. And I think as such, it needs to be talked about. It needs to be explored and understood, and even debated. It needs to be out in the open. The last thing that should happen is that it happens behind closed doors.
One of the reasons I wrote this book is to contribute to the conversation around death and dying, and around end-of-life care options in general. Whether you believe in assisted dying or not, I think these are conversations that Canadians need to have, and I hope that my book facilitates those conversations. For me, that would be success.
SG: I do it with sensitivity, with honesty, with direct information, without inflammatory language, with respect to those who might have a different opinion and with curiosity about what other people think and why. I think those are the main things that you must keep in mind when discussing this topic.
SG: If somebody in Canada wants to have an assisted death, they need to ask for it themselves. They need to make a formal request in writing which needs to be signed and dated and witnessed. And once that happens, it triggers the next process. They need to be assessed by a clinician, either an MD or a physician or nurse practitioner to see if they meet the eligibility criteria, which are rigorous and robust. Two different clinicians need independently to agree that they meet those conditions.
And if they do, then they have the possibility of having assisted death. Once the eligibility criteria are met, there are several procedural safeguards. Things like having that request form in writing and dated, things like giving consent. There’s a whole list of other safeguards that need to be met. If the two independent physicians agree that you meet all the conditions, then then it’s up to the patient—but that still doesn’t mean it’s going to happen. It means it can happen if the patient feels truly necessary. And then it’s just a logistical matter about organizing and choreographing the final event. Scheduling it, making sure all the factors and pieces are in place, the medications, the nursing support, things like that. That’s the process.
SG: The one thing that I would like to stress is that I am a co-founder and president of a national organization that supports the people that do this work, the Canadian Association of MAiD Assessors and Providers (CAMAP). And I think it’s important that people know that the clinicians and the teams of professionals that support them take this work very seriously. This is not something people enter into lightly. This is not something people do without a lot of thought and careful consideration. The clinicians that do this work do it professionally, responsibly, and rigorously.