Hastened death— “Using medications to commit suicide”

Participants shared several stories about patients who were considering DWD but pursued alternative means to hasten death. Both of the following stories indicate how discussing suicide is relevant in the discourse of experiences with DWD. Reasons why patients did not begin or complete the process of DWD in these stories include not having information about legal options or the desire or ability to follow through with the DWD process. In some stories, the death of the patient was entered as suicide on the death certificate. In other stories, the cause of death was listed as the disease depending on whether the death was reported as a suicide:

“One very ill woman with advanced cancer took all of her comfort medicines in a suicide attempt...she was thinking about pursuing death with dignity, but she didn’t…she just took all of her meds…she ended up dying of a medicine overdose, and so technically it was a suicide that we had to put on her death certificate, but if it was a death with dignity, you put the cause of whatever the terminal illness was…so that’s a pretty big distinction there…It’s a fine line but it is a distinction.” MD1

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The distinctive ‘fine line’ discussed by MD1 emphasises that because the death wasn’t within the guidelines of the DWDA and instead from an overdose of prescribed medications, it is called suicide. But, in the end, the patient has controlled timing of death in both situations. This fine line—the boundary between what is and is not classified as suicide—is very blurry, especially when the cause of death is not listed as suicide, but the professional is aware the patient used hospice medications to hasten death:

“...a couple of incidents where patients have ended their own lives with the hospice prescribed medication, ... at least in one case it wasn’t someone who was pursuing death with dignity, and in another case, it was somebody who was actively pursuing the Death with Dignity law....so they used their hospice related medications to commit suicide.” MD3

Patients may not know, however, how much medication will be effective to end life, and if they would suffer in the process of taking the medication.

MSW5 told stories of patients who went through the process of medical aid in dying but then hastened death with an intentional overdose from drugs obtained illegally or medications saved from previous prescriptions, because of their lack of access to legal life-ending medications from local pharmacies:

“... and everything was going along and then he got his prescription, and the pharmacy didn’t have his medication, saying they would have to order

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it....and at that point in time, he was frustrated with the whole process and took all of his morphine and all of his Lorazepam that was in the home, and became unconscious and died.” MSW5

Thus, MSW5 explains that lack of access to DWDA medications was the cause of this patient dying of an overdose from comfort medications that were prescribed to him, but not prescribed for ending life. However, the death of this patient was not identified as a suicide by the hospice team or the coroner, another indication that open discussion about the patient’s death could cause additional grief for families or complications for the professional who may be held accountable if the death is deemed a suicide. If the social worker assessed the patient for suicidal ideation and found them not to be at risk then they could not necessarily be held responsible; however, they might feel responsible for the death. In some cases, participants suggested that family members knew and supported a patient's intent to hasten death. However, all healthcare providers are required to report when patients are at risk of harm to themselves, which may cause some professionals to feel conflicted when determining and reporting risk when a patient seeks but is unable to obtain DWD and intentionally ends their life in another way.

Participants also shared stories of patients who took an intentional overdose of medications years prior to the passing of the DWDA. Several of these deaths were not identified as suicide:

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to, I wouldn’t say commit suicide, but make themselves just go out unconscious.” RN6

RN6 thinks that patients purposefully hastened their death with hospice medications, and the circumstances of these deaths were not discussed openly as suicides, or intentionally hastened deaths. MSW1 had also experienced similar situations:

“I have direct experience with a patient who took all of his medications... knowing that the nurse and I were coming ... And he had expired... And because when he was on hospice the cause of death is presumed to be the disease process ... it was not classified as suicide by the coroner, it was classified as death by disease... he was sitting upright when we found him, and his medications were not there, so it seems like that’s what it was, given what I knew about him ...it was his desire to be in control of how he died, even though he didn’t use a formal program that was sanctioned culturally and legally.” MSW1

The stories of MSW1 and RN6 both indicate that patients receiving home hospice services have died by suicide both before and after the DWDA was implemented. Healthcare professionals want to support the patient to end suffering, however, it is as if they are put in the position of power betraying the patient if they call a death from intentional overdose a suicide. Participants imply that these stories are not easily shared and that lack of open communication about these deaths cause added emotional distress. Professionals may be afraid to speak openly about suicide

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because they feel responsible for not being able to help someone experience a natural death free from pain and suffering.

6.2.2 Palliative Sedation as an alternative to DWD— “Asking us to do it for them”