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MD aid in dying: what to put on the death certificate?

Quebec says MD-assisted death should not be listed on the patient's death certificate. A new article in CMAJ disagrees. Turns out it's complicated.
Veronique Hivon, Quebec's minister for social services and youth protection, has been leading the Bill 52 initiative, which would allow medical aid in dying. (Jacques Boissinot/Canadian Press)

Quebec's law allowing medical aid in dying came into effect last Thursday.This means doctors are now permitted to administer lethal drugs to terminally ill patients who want the option at least until this Friday (December 18), when the province's Court of Appeal hears arguments on the issue. Ahead of the law's introduction, Quebec doctors were advised NOT to list medical aid in dying on death certificates.That idea has been criticized in an article just published in the current issue of the Canadian Medical Association Journal (CMAJ).

A death certificate has the deceased person's full name, address, date of birth, as well as date, time, and place of death.  The authors of the article in CMAJ obtained a copy of the death certificate from most of Canada's 12 provinces and territories.  In general, they ask for the immediate cause of death and the antecedent causes.  There is also space for the doctor to write down a list of the other significant factors or diseases that contributed to the death - those that are not related directly and immediately to the death.  The death certificate also has space for the doctor to estimate the interval of time between the onset of each cause or condition and death.  As a medical doctor in the ER, I've filled out my fair share of death certificates.

The authors argue in CMAJ that since the death certificate is a legal document, it should be accurate.They say a death certificate can be used in establishing legal accountability for death or liability for payment on life insurance policies. For example, some life insurance policies have exclusions in the contract that might prevent the insurer from paying out.

Death certificates are also used as a source of data for mortality statistics. Those statistics are used by governments to allocate resources for health care as well as research.  Putting medical aid in dying on the death certificates allows policy makers to capture the deaths of people who had help in dying without having to sample other death certificates looking for clues.

So just what motivated the people implementing Quebec's law to ask doctors to leave medical aid in dying off the death certificate? I spoke with Dr. Yves Robert, Secretary of the Quebec College of Physicians. The college has been getting doctors there ready to implement the new law. Dr. Robert says lawyers advised the province and the college to leave medical aid in dying off the death certificate to ensure that life insurance benefits are paid out to survivors.  He says the college worries that insurance companies could use the death certificate to deny a claim, refuse to pay beneficiaries, or use the death certificate to delay payment.  He also told me the other reason for leaving it off the death certificate is the very public nature of that particular document.  Anyone can look up a death certificate - including family members and others that the deceased patient may not want to know that they received help to die from a doctor.

If a doctor's aid in dying is left off the death certificate, how do authorities keep tabs on the practice? Quebec authorities say the medical records must contain a form dated and signed by the patient that makes the request for medical aid in dying clear.  In each instance, a confidential report will be sent to the college, the hospital and to the provincial Commission on End-of-Life care.  The Quebec law says the physician must inform the Commission of providing medical aid in dying to a patient within 10 days after the patient's death. It's the job of the Commission to assess whether the rules were followed - that the patient was an insured person within Quebec and not a medical tourist from another province, of full age and capable of giving consent to care, at the end of life, suffering from a serious and incurable illness, and experiencing constant and unbearable physical or psychological pain which cannot be relieved.  The Commission will submit an annual activity report to the Minister of Health.

The issue of medical aid in dying is moving to the front burner in Canada. Currently, the Supreme Court's decision comes into effect on February 6, 2016. The federal government has asked for an extension.  A federal external panel is scheduled to provide a report to the federal government on December 15 on the findings and results of its own consultations.

I don't necessarily see the Quebec method being adopted by other provinces.The authors of the article in CMAJ give several ways in which a MD-assisted death could be recorded on the death certificate. It could be categorized as 'unnatural under 'manner of death' - as opposed to a natural death brought about directly by a disease or condition.  Alternatively, physician assisted death could be listed under cause of death, with the disease that qualifies the patient for assisted death listed as the underlying cause, the MD assisted death listed as the subsequent antecedent cause, and the physical sequelae of the lethal injection listed as the immediate cause of death. 

The point the authors make is just because doctor assisted death is new doesn't mean it can't be put on death certificate using time honoured principles. I'm inclined to agree with them.  Still, it's just one more thing to think about as Canada starts the conversation on medical aid in dying. I think this is a rare misstep by a province that - for the most part - has gotten the process right.

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