Gallagher Romayne, Passmore Michael J, Baldwin Caroline
Division of Palliative Medicine, Department of Family and Community Medicine, Providence Health Care, Vancouver, Canada; Department of Family Medicine, University of British Columbia, Vancouver, Canada.
Department of Psychiatry, Providence Health Care, Vancouver, Canada; Division of Geriatric Psychiatry, University of British Columbia, Vancouver, Canada.
Med Hypotheses. 2020 Sep;142:109727. doi: 10.1016/j.mehy.2020.109727. Epub 2020 Apr 16.
All healthcare services strive to achieve the six factors of quality health care - safe, effective, patient-centered, timely, efficient and equitable. Yet multiple structural, process, policy and people factors can combine to result in medical error and patient harm. Measuring the quality of palliative care has many challenges due to its presence across multiple health sectors, variable skill and experience of providers and lack of defined processes for providing services. In Canada there is screening for symptoms and distress in most cancer centers, but not in non-cancer diseases. Screening for distress and disease burden can identify suffering, that when properly addressed, improves quality of life and reduces depression and hopelessness that can lead to requests for hastened death. Our hypothesis is that some requests for hastened death (known as Medical Assistance in Dying or MAiD in Canada) are driven by lack of access to palliative care or lack of quality in the palliative care attempting to address disease burden and distress such that the resulting provision of hastened death is a medical error. The root cause of the error is in the lack of quality palliative care in the previous weeks, months and years of the disease trajectory - a known therapy that the system fails to provide. The evidence for palliative care addressing symptoms and improving quality of life and mood as well as providing caregiver support is established. Early evidence supporting the use of psychotherapeutics in emotional and existential distress is also considered. We present three cases of request for assisted death that could be considered medical error. The paper references preliminary evidence from a review of previous access to palliative care in a limited number of MAiD cases showing that only a minority were identified as having palliative care needs prior to the admission where MAiD was provided. The evidence linking disease burden to hopelessness, depression and hastened death is provided. The many studies revealing the inequity or underservicing of the Canadian population with regards to palliative care are reviewed. We examine a recent framework for palliative care in Canada and point out the need for more aggressive use of standards, process and policies to ensure that Canadians are receiving quality palliative care and that it is equitably accessible to all.
所有医疗服务都努力实现优质医疗的六个要素——安全、有效、以患者为中心、及时、高效和公平。然而，多种结构、流程、政策和人员因素可能共同导致医疗差错和患者伤害。由于姑息治疗存在于多个卫生部门，提供者的技能和经验参差不齐，且缺乏明确的服务提供流程，因此衡量姑息治疗的质量面临诸多挑战。在加拿大，大多数癌症中心会对症状和痛苦进行筛查，但非癌症疾病领域则不会。对痛苦和疾病负担进行筛查可以识别出患者的痛苦，若能得到妥善处理，就能提高生活质量，减轻可能导致加速死亡请求的抑郁和绝望情绪。我们的假设是，一些加速死亡的请求（在加拿大称为医疗协助死亡或MAiD）是由于无法获得姑息治疗或试图应对疾病负担和痛苦的姑息治疗质量不佳所致，以至于最终提供的加速死亡是一种医疗差错。差错的根本原因在于在疾病发展轨迹的前几周、几个月甚至几年里缺乏优质的姑息治疗——这是一种该系统未能提供的已知疗法。姑息治疗能够缓解症状、改善生活质量和情绪以及为护理者提供支持的证据是确凿的。早期支持在情感和生存痛苦中使用心理治疗方法的证据也得到了考量。我们呈现了三例可被视为医疗差错的协助死亡请求案例。本文引用了对有限数量的医疗协助死亡案例中先前获得姑息治疗情况的回顾得出的初步证据，表明在提供医疗协助死亡的入院前，只有少数人被确定有姑息治疗需求。文中提供了将疾病负担与绝望、抑郁和加速死亡联系起来的证据。对众多揭示加拿大民众在姑息治疗方面存在不公平或服务不足情况的研究进行了综述。我们审视了加拿大近期的姑息治疗框架，并指出需要更积极地运用标准、流程和政策，以确保加拿大人能够获得优质的姑息治疗，并且所有人都能公平地获得。
