Family questions criteria after euthanization of Canadian man

After Alan Nichols' death by voluntary euthanasia at a British Columbia hospital in July, his family have questioned the imprecision of Canada's requirements for euthanasia and assisted suicide, which include having "a grievous and irremediable medical condition."

Vancouver, Canada, (CNA) - After Alan Nichols' death by voluntary euthanasia at a British Columbia hospital in July, his family have questioned the imprecision of Canada's requirements for euthanasia and assisted suicide, which include having "a grievous and irremediable medical condition."

They doubt Nichols was able to give informed consent to his euthanization, and maintain his natural death was not reasonably foreseeable.

According to a Sept. 24 article in CTV News based on accounts from Nichols' family and a neighbor, Nichols was admitted to Chilliwack General Hospital, about 60 miles east of Vancouver, after he was found in poor physical condition at his home in mid-June.

Nichols, who was 61, was euthanized July 26 at the hospital by medical staff who delivered three injections.

"He didn't have a life-threatening disease. He was capable of getting around. He was capable of doing almost anything that you had to do to survive," his brother, Gary Nichols, told CTV News. "I didn't think he had a sound mind at all."

Nichols had received brain surgery at age 12, and had lost his hearing and had a cochlear implant. He developed depression, and took medication to treat it. But after the death of his father in 2004, he was inconsistent about taking his antidepressants.

Gary Nichols, Alan's brother, told CTV News: "He would have maybe a period, a year, he would be very easy to deal with and make some decent changes. But then he would fall back into a very depressed state. Not going out in public, not seeing anybody, not eating properly."

Nichols' family tried to get guardianship over him in 2015, but could not get permission to do so.

Once Nichols was in hospital, his family said that the staff were reticent to speak to them about his status.

A doctor phoned July 22 to say that Nichols was scheduled to be euthanized in four days.

Gary said he "never thought [Alan] would ever be approved even if he applied" for euthanasia or assisted suicide.

The family indicated they did not support the decision, and were unable to stop it from being carried out.

According to CTV News, Nichols' family were told two doctors had approved his application for euthanasia "and that a psychologist and psychiatrist were there to assess Nichols' competence."

In British Columbia, the death certificate of those who are euthanized or commit assisted suicide list Medical Assistance in Dying as the immediate cause of death, with antecedent causes giving rise to the euthanization or assisted suicide listed subsequently.

Nichols' death certificate lists stroke, seizure disorder, and frailty as causes antecedent to his euthanization, according to CTV News.

Trish Nichols, Alan's sister-in-law, said that "Alan did not fit the criteria. Alan was capable of talking, he was sitting up, he was eating, he was going to the bathroom, we were laughing, he was out of bed. I knew by looking at him that he still had living to do. He was not near the end of his life."

"How can you allow this with Alan, knowing his background of mental anguish and depression?" Trish asked.

"We spent 50 years helping Alan live, and in one month they signed his death warrant. How can that happen in that period of time? Where's the legislation to protect us?"

The family have asked the Royal Canadian Mounted Police to investigate Nichols death; they say the police service directed them to the provincial health ministry.

Nichols' case highlights the lack of clarity over the criteria for euthanasia and assisted suicide in Canada, which have also been pointed out by disability advocates, pro-life groups, and bioethicists.

Eligibility is restricted to mentally competent Canadian adults who have a serious, irreversible illness, disease, or disability. While to be eligible a patient does not have to have a fatal condition, they must meet a criterion variously expressed as they "can expect to die in the near future", that natural death is "reasonably foreseeable" in the "not too distant" future, or that they are "declining towards death".

Fraser Health, which oversees Chilliwack General Hospital, lists on its website 10 criteria for eligibility for euthanasia or assisted suicide. In addition to having "a serious and incurable illness, disease or disability" and suffering "unbearably from my medical condition", one criterion is that "My doctors have told me I can expect to die in the near future."

The first step toward receiving euthanasia or assisted suicide, according to Fraser Health, is to "talk with others". It instructs patients to "Talk to your family, loved ones and other people in your life who can support you."

Fraser Health says that two doctors or nurse practitioners "assess you separately to make sure you are eligible for an assisted death and are capable of deciding. They must agree you meet all the criteria."

Among the statements that a patient must confirm on a euthanasia-assisted suicide request form provided by the BC Ministry of Health is that "I believe that my medical condition is grievous and irremediable, my suffering is intolerable, there are no treatments that I consider acceptable, I am in an advanced state of irreversible decline, and my death is reasonably foreseeable." The form also includes a space for the "Medical Diagnosis Relevant to Request for Medical Assistance in Dying".

According to Health Canada, among the eligibility criteria for euthanasia or assisted suicide are that you "have a grievous and irremediable medical condition" and "give informed consent to receive medical assistance in dying".

The national health ministry says that to have a grievous and irremediable medical condition, you must "have a serious illness, disease, or disability"; "be in an advanced state of decline that cannot be reversed"; "experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable"; and "be at a point where your natural death has become reasonably foreseeable", which "takes into account all of your medical circumstances and does not require a specific prognosis as to how long you have left to live". It specifies that "you do not need to have a fatal or terminal condition to be eligible for medical assistance in dying." It adds that "your natural death must be foreseeable in a period of time that is not too distant".

The Canadian health ministry also says that "you must be mentally competent and capable of making decisions" both "at the time of your request" and "immediately before medical assistance in dying is provided."

According to the health ministry, many of the drugs commonly used in euthanasia and assisted suicide "are already marketed in Canada and are prescribed at lower dosages for common purposes," such as nausea, pain control, and anaesthesia.

The national health ministry says there are safeguards to insure that those requesting euthanasia or assisted suicide "are able to make health care decisions for themselves" and "request the service of their own free will".

According to the practice standard of the College of Physicians and Surgeons of British Columbia, "the federal government has indicated that MAiD is intended to be restricted to those individuals who are declining towards death, allowing them to choose a peaceful death as opposed to a prolonged, painful or difficult one."

The practice standard also notes that the patient requesting euthanasia or assisted suicide "must be competent and able to give free and informed consent," and that both of two independent medical assessors "must be satisfied that the patient is mentally capable of making a free and informed decision at the time of the request and throughout the process."

It adds that "if either MA is unsure that the patient has capacity to consent to MAiD, the patient must be referred to another practitioner with current expertise in capacity assessment, such as a psychologist, psychiatrist, neurologist, geriatrician, or FP/GP with additional training or experience for a further in-person capacity assessment."

At least 6,749 Canadians have died of euthanasia or assisted suicide since legislative enactment (Dec. 10, 2015 in Quebec, and June 17, 2016 in the rest of Canada), according to Health Canada.

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