Circle of life: Former Victoria maternity doctor now helps terminally ill people end their suffering

Dr. Stefanie Green in her Victoria office this week. Green, who started her career as a maternity doctor, has provided medical assistance in dying to 25 people over the past eight months, people who want to depart this life on their own terms in the face of painful and imminent death.

By Randy Shore

For Stefanie Green, the transition from baby doctor to helping people die was completely natural, providing care at different ends of life’s continuum. 

“I (originally) chose maternity and I liked the fact that it was happy medicine, and really I can’t think of a better job on the planet than delivering babies,” she said. “I was in in my 20s when I started, so it felt (like) really familiar territory because I was also getting married and having kids.”

But helping people to die is not so different when the dominant emotion is not sadness, but gratitude.

Green has provided medical assistance in dying to 25 people over the past seven months, people who want to depart this life on their own terms in the face of painful and imminent death.

“The overwhelming emotion in the room when I provide this care is relief and gratitude,” said Green, a Victoria-based physician with 20 years experience in maternity care. “There is a release from suffering. The family is overwhelmingly grateful. The patient is overwhelmingly grateful.

“There is a real satisfaction on the part of the patient, who has made an empowering decision and been able to fulfill it after years of pain and hopelessness.”

Death review panel

About 200 people in British Columbia have opted for a medically assisted death since last June 17 when Bill C-14 created a legal environment for assisted dying. More than 740 Canadians died with medical assistance in 2016.

With six-plus months of data now in hand, the B.C. Coroner’s Service — with representatives of the health regions and the provincial government — plans a Death Review Panel for later this month to assess the new process. A report will be made public later this year.

As a young doctor, Green took careful note of celebrated B.C. right-to-die cases, including the 1994 death of Sue Rodriguez and, more recently, the 2012 B.C. Supreme Court decision that would have allowed Gloria Taylor the right to end her life. But it wasn’t until Green took a break from her maternity practice two years ago that she considered changing the focus of her career.

“When I realized that our laws were truly about to change and there was an opportunity to work in this new field I really began to educate myself,” she said.

There is a release from suffering. The family is overwhelmingly grateful. The patient is overwhelmingly grateful’ — Stefanie Green, provider of medical assistance in dying

After attending the 2016 conference of the World Federation of Right to Die Societies in Amsterdam, Green felt sure of her new course.

“Talking to people in the field, they were talking about choreographing the death,” she said. “Everything I heard sounded a lot like preparing for a birth. I really saw how those skills were going to be transferrable from one to the other.”

“There’s an art to making sure everything is going as smoothly and safely as possible during a delivery while still understanding you aren’t the most important person in the room,” she said. “I find that is the skill I take the most with me to end-of-life care.”

Public demand

The new law appears to have tapped public demand, as almost one person per day receives medical assistance in dying in B.C. 

“When people come to me they have made a decision that they want this service,” said Green. “People are decided, courageous and very determined. They’ve made the leap.”

But not everyone who wants a medically assisted death can get it.

The federal law includes a criterion not found in the B.C. Supreme Court ruling, namely that the patient’s natural death “has become reasonably foreseeable.”

“It’s not exactly clear what that means,” said Green. “For someone who can’t make a clear case, it’s a difficult box to tick. I’ve had to say no to people and it’s the hardest part of the job, but I need to work within the law.” 

The vast majority of Green’s patients are in the terminal stages of cancer and many of the others are in end-stage failure of the heart, liver or lungs. Most remain lucid right to the end, and importantly able to consent or decline the procedure to their final moments of life.

With some neurodegenerative diseases, the accelerating loss of mental capacity can muddy the waters.

“When people come too late in the course of their disease, it’s a problem,” she explained. “It may be that they are well enough to make the decision when I meet them, but they decline so quickly that they become confused and we have to stop the process.”

MAiD becoming normalized

Green is convinced many people will come to view medical assistance in dying — MAiD for short — as it becomes a normal part of medical care in a continuum that includes prenatal and preventative care, aggressive therapy for illness, hand-holding when treatments aren’t working and palliative care for those who seek comfort at the end of their lives.

She is adamant that the obligation to provide care does not stop five weeks or even five seconds before death.

“MAiD is just another part of that spectrum. Some people really need to fight to the last breath and some people really need to call the shot at the end,” she said. “The Canadian public understands very well what this care is and 87 per cent of them support it. I think that’s very humane.”

Complete Article HERE!

End of life pain control important consideration

By DR. GIFFORD JONES
[W]oody Allen, when asked for his opinion about death, replied, “I don’t worry about dying, I just don’t want to be there when it happens!”

Unfortunately, Allen will be there and so will the rest of us. This week, I have a personal interest in the end of life.  And what can we all do to provide the best of care to loved ones near death?

Years ago I conducted a five-year battle to legalize heroin to ease the agony of dying cancer patients. Readers, at that time, sent me funds to help with costs. Finally, when heroin was legalized in 1998, $450,000 was left in the kitty, which I donated to the University of Toronto, Faculty of Medicine to establish the Gifford-Jones Professorship in pain control and palliative care. For an update of the current situation, I recently interviewed Dr. Jeff Myers, the current professor of palliative care.  

Myers and his colleagues have not been idle. Today, many doctors are being trained in palliative care. There are now more hospital beds to care for dying patients along with better symptom control. But some “ifs” remain. 

I asked Myers what was the stumbling block surrounding palliative care. He replied: “The reality is, 100 per cent of us will eventually die. So faced with this indisputable fact we must ensure we depart in the most humane way possible.”

This means total and effective palliative care for every person.

Myers reported one shocking problem. Some doctors are not providing adequate painkillers, even when patients have only a short time to live, for fear of causing addiction. This reasoning boggles my mind as years ago I heard this same asinine argument when I was trying to legalize heroin for patients in agony at death’s door.

Myers is concerned this reluctance will be compounded by the current epidemic of opioid drug deaths. Since doctors are being blamed for causing this problem by over-prescribing opioids, they may be less likely to prescribe them to dying patients. But from my research dying patients do not become addicted to painkillers when they are used for pain. Addiction occurs when drugs are used repeatedly for pleasure. So let’s stop blaming doctors for all of the opioid deaths.

Another major obstacle according to Myers is that medical students get very few hours of training in palliative care. This is concerning, given the universal need.

Today the Supreme Court of Canada and some U.S states have declared a legal right to request doctor assisted death. But we do not have a right to adequate palliative care.

The brutal truth is that for the majority of people palliative care is not an option as it is just not available. For example, today 40 per cent of cancer patients do not get palliative care during their final year of life. And, in some areas of the country, less than half of those who die in a hospital receive palliative care.

The problem will get worse as today 80 per cent of patients being treated in palliative care facilities are suffering from cancer. Since we are an aging population the demand for palliative care centers will increase.  

Dr. Francis W. Peabody, professor at The Harvard Medical School, is remembered for saying, “The secret of caring for the patient is caring for the patient.”

There is no better example than caring for loved ones at the end of life.

So what can be done to assure we leave this planet with the least possible trauma? The primary need is to fund the training of doctors and other medical personnel in palliative care.

Like Woody Allen we’d all prefer not to be there when death occurs. But unless we quickly discover Ponce de Leon’s Fountain of Youth, you can be assured you will be there sooner or later.

Complete Article HERE!

How to Overcome the Fear of Death, Part 5

Finding Support

1

Determine if you need to seek help from a mental health therapist. If your fear of death has become so intense that it is interfering with your ability to carry out normal activities and enjoy your life, you should seek the help of a licensed mental health therapist. For example, if you start avoiding certain activities due to your fear of impending death, then it is time to get help.[23] Other signs that you may need to seek help include:

  • feeling disabled, panicky, or depressed because of your fear
  • feeling like your fear is unreasonable
  • dealing with the fear for more than 6 months

2

Understand what you can expect from a mental health therapist. A therapist can help you to better understand your fear of death and find ways to minimize it and hopefully overcome it. Keep in mind that dealing with a profound fear takes time and effort. It can take a while before your fears become manageable, but some people see a dramatic improvement in just 8-10 therapy sessions. Some of the strategies that your therapist might use include:[24]

  • Cognitive Behavioral Therapy: If you are afraid of dying, you may have certain thought processes that intensify your fear. Cognitive behavioral therapy is a method that therapists use to get you to challenge your thoughts and identify the emotions associated with those thoughts. For example, you may think to yourself, “I can’t fly because I am afraid the plane will crash and I will die.” Your therapist will challenge you to realize that this thought is unrealistic, perhaps by explaining that flying is actually safer than driving. Then, you will be challenge to revise the thought so that it is more realistic, such as, “People fly on planes every day and they are fine. I am sure that I will be fine too.”[25]
  • Exposure Therapy: If you are afraid of dying, you may start avoiding certain situations, activities, and places that intensify your fear. Exposure therapy will force you to confront that fear head on. In this type of therapy, your therapist will either ask you to imagine that you are in the situation you have been avoiding or they will ask you to actually put yourself into the situation. For example, if you have been avoiding flying because you are afraid the plane will crash and you will die, your therapist may ask you to imagine that you are on a plane and describe the way you feel. Later, your therapist may challenge you to actually fly on a plane.[26]
  • Medications: If your fear of dying is so profound that it is causing you to have severe anxiety, your therapist may refer you to a psychiatrist who can prescribe medicine that may help you. Keep in mind that the medicines used to treat anxiety associated with fear will only reduce your anxiety temporarily. They will not take care of the root cause.[27]

3

Share your thoughts on death and dying with others. It’s always good to talk to someone about your fears or anxiety. Others may be able to share similar concerns. They may also suggest methods that they’ve used for dealing with the associated stress.[28]

  • Find someone you trust and explain to her what you think and feel about death, and how long you’ve felt this way.

4

Visit a death café. Issues related to death and dying can be particularly difficult for people to talk about in general. It is important to find the right group with whom to share your ideas regarding these issues. [29] There are “death cafes,” which are groups of people who meet in cafes specifically to discuss issues around death. These are essentially support groups for people looking to handle their emotions around death. The groups determine together how to best live life in the face of death.

  • If you cannot find one of these cafes near you, consider starting your own. Odds are there will be lots of people in your area with concerns about death but who haven’t had the opportunity to share their concerns.

Look for Part 1 HERE!
Look for Part 2 HERE!
Look for Part 3 HERE!
Look for Part 4 HERE!

How to Overcome the Fear of Death, Part 4

Living Life

1

Live life to the fullest. Ultimately, it’s best to avoid spending too much time worrying about death and dying. Instead, fill each day with as much joy as possible. Don’t let little things get you down. Go outside, play with friends, or take up a new sport. Just do anything that will take your mind off dying. Instead, focus your mind on living.

  • Many people with the fear of death think about it daily. It means that you have a lot of things you want to do in life. Let the fear work through and ask yourself, “What is the worst thing that will happen today?” Today you are alive, so go and live.

2

Spend time with your loved ones. Surround yourself with people that make you happy and vice versa. Your time will be well-spent – and well-remembered – when you share yourself with others.

    • For example, you can rest assured that your memory will live on after you die if you help your grandchildren develop happy memories of you.

3

Keep a gratitude journal. A gratitude journal is a way for you to write down and acknowledge the things you’re thankful for. This will help keep your focus on the good things in your life.[22] Think of good things about your life and cherish them.

      • Take some time every few days to write down a moment or thing that you’re grateful for. Write in depth, savoring the moment and appreciating the joy you’ve received from it.

4

4

Take care of yourself. Avoid getting involved in bad situations or doing things that can raise your chances of dying. Avoid unhealthy activities like smoking, drug or alcohol abuse, and texting while driving. Staying healthy removes some of the risk factors that can lead to death.

Look for Part 1 HERE!
Look for Part 2 HERE!
Look for Part 3 HERE!

How to Overcome the Fear of Death, Part 3

Reflecting On Life

1

Consider how life and death are part of the same cycle. Recognize that your own life and death, as well as the lives of other creatures, are all parts of the same cycle or life-process. Life and death, rather than being two completely different events, are actually always occurring at the same time. The cells in our bodies, for example, are continuously dying and regenerating in different ways throughout an individual lifetime. This helps our bodies adapt and grow within the world around us.[16]

2

Think about how your body is part of a complex ecosystem. Our bodies serve as fertile ecosystems for countless different life forms, especially after our own lives come to an end.[17] While we are alive, our gastrointestinal system is home to millions of micro-organisms. These all help our bodies stay healthy enough to support proper immune functioning, and, in certain ways, even complex cognitive processing.[18]

3

Know the role your body plays in the grand scheme of things. On a much larger, macro level, our lives fit together in unique ways to form societies and local communities which depend upon our bodies’ energy and actions in order to sustain some degree of organization.[19]

  • Your own life is composed of the same mechanisms and materials as other lives around you. Understanding this point can help you become more comfortable with the thought of a world without your particular self still being around. [20]

4

Spend time in nature. Go on meditative walks in nature. Or, you can simply spend more time outside around many different life forms. These activities can be great ways to become more comfortable with the realization that you’re a part of a larger world. [21]

5

Consider the afterlife. Try thinking that after you die you will go somewhere happy. Many religions believe in this. If you ascribe to a particular religion, you may find comfort in considering what your religion believes about the afterlife.

Look for Part 1 HERE!
Look for Part 2 HERE!

How to Overcome the Fear of Death, Part 2

Letting Go of What You Can’t Control

 

1

Focus on what you can control. Death can be an especially frightening thing to think about, primarily because it exposes the limits of life and what we are able to conceive. Learn to focus on what you can actually control while still engaging with what you cannot.

  • For example, you may be worried about dying from a heart attack. There are certain factors that you can’t control about heart disease, such as family history, race and ethnicity, and age. You will make yourself more anxious by focusing on these things. Instead, it’s far healthier to focus on the things you can control, like quitting smoking, exercising regularly, and eating well. In fact, you are at higher risk for heart disease when you have an unhealthy lifestyle than just by the uncontrollable factors alone.[8]

2

Guide your life. When we want to control the direction of our lives, we are often met with disappointment, frustration and anxiety about things that don’t go as planned. Learn to loosen your grip on how tightly you control the outcomes of your life. You can still make plans, of course. Guide the course of your life. But allow some room for the unexpected.[9]

  • A fitting analogy is the idea of water flowing in a river. Sometimes the river bank will change, the river will curve, and the water will slow down or speed up. The river is still flowing, but you have to let it go where it takes you.

3

Eliminate unproductive thought patterns. When you try to predict or imagine the future, you find yourself asking, “What if this happens?” This is an unproductive thought pattern known as catastrophizing.[10] An unproductive thought pattern is a way of thinking about a situation that ultimately causes you to have negative emotions. How we interpret an event will result in the emotion we feel from it. For example, if you are worried that you’re late for work, you might tell yourself, “If I’m late, I will get reprimanded by my boss and I’ll lose my job.” Having unproductive thought patterns can put you on edge if you feel like you want to control the outcome so strongly.

  • Replace unproductive thinking with positive thinking. Reason through your unproductive thought patterns. For example, say to yourself, “If I’m late, my boss might get mad. But I can explain that there was more traffic than normal. I’ll also offer to stay late after work to make up the time.”

4

Have a worry time period. Devote five minutes during the day when you will allow yourself to worry about something. Do this at the same time every day. Try not to schedule this worry period for bedtime, because you don’t want to lay in bed fretting over things. If you have a worrying thought any other time during the day, save it for your worry time period. [11]

5

Challenge your anxious thoughts. If you are struck with anxieties about death, ask yourself about the chances of dying in certain scenarios. Arm yourself with statistics about dying in a plane crash, for example. You will likely find that your worries are inflated beyond the reality of what could possibly happen. [12]

6

Think about how you’re affected by others. When other people’s worries start taking over your mind, you’ll think more about risks too. Perhaps you have a friend who is particularly negative about diseases and illnesses. This causes you to feel nervous about getting ill yourself. Limit time you spend with this person so that these thoughts don’t enter into your head so frequently. [13]

7

Try something you’ve never done before. We often avoid trying new things and putting ourselves in new situations precisely because of fears regarding what we do not yet know or cannot yet understand.[14] In order to practice letting go of control, pick an activity you’d never consider doing and commit to giving it a try. Start by doing some research on it online. Next, maybe talk to people who have participated in the activity before. As you start to become more comfortable with the idea of it, see if you can’t give it a try once or twice before making an especially long commitment to it.

  • This method of experimenting with life and new activities can be a great tool for learning how to focus on producing joy in life as opposed to worrying about death and dying.
  • As you participate in new activities, you will likely learn a lot about yourself, especially in regard to what you can and cannot control.

8

Develop an end-of-life plan with your family and friends. When it comes to death, you will likely come to realize that most of the process will be completely out of your control. There’s no way we can ever know for sure exactly when or where we can die, but we can take some steps so as to become more prepared. [15]

  • If you are in coma, for example, how long would you want to remain on life support? Do you prefer to pass in your home or remain in the hospital as long as possible?
  • It might be uncomfortable about these issues with your loved ones at first talking, but such conversations can be incredibly helpful for both you and them if an unfortunate event arises and you are unable to express your desires in the moment. Such discussions might potentially help you feel a little less anxious towards death.

Look for Part 1 HERE!

How to Overcome the Fear of Death, Part 1

[T]hanatophobia, or “fear of death,” affects millions of people worldwide. For some people, it can produce anxiety and/or obsessional thoughts. [1] While thanatophobia is the fear of death and/or one’s own mortality, a fear of dying people or dead things is known as “necrophobia,” which is different from thanatophobia. Both of these fears, however, can be similarly related to a fear of the unknown aspects related to death, known as “xenophobia.” In another sense, it is the possibility of encountering something beyond what is already known. [2] This can be especially true for people who are nearing the end of life, as uncertainties around the death process can multiply as the reality of death becomes more imminent.[3] In order to become more comfortable with the unknown end of life, you need to understand your phobia and work to overcome its hold on you.

1

Write down the times when you think about death. The first thing to determine when dealing with a fear of death is how – and how much – your fear affects your life. We are not often immediately aware of the environmental triggers or causes of our fears and anxiety. Writing about the situations in which they arise can be a helpful tool for working through these issues.[4]

  • Start by simply asking yourself, “What was going on around me when I started feeling afraid or anxious in that moment?” For a number of reasons, this can be a very difficult question to answer at first. Start with the basics. Think back over the last few days and write down as many details as you can remember about the times you thought about death. Include exactly what you were doing when the thoughts arose.
  • The fear of death is very common. Throughout human history, people have been concerned and preoccupied with the idea of death and dying. This can happen for several reasons, including your age, your religion, your level of anxiety, the experience of loss, and so on. For example, during certain transitional phases in your life, you may be more prone to having a fear of death. People may have a deeper preoccupation with death in the ages 4-6, 10-12, 17-24, and 35-55.[5] Scholars have long philosophized about the prospect of death. According to the existentialist philosopher Jean-Paul Sartre, death can be a source of fear for people precisely because it is that which “comes to us from the outside and transforms us into the outside.” [6] The process of death, therefore, represents to us the most radical unknown dimension imaginable (or, in a sense, unimaginable). As Sartre points out, death has the potential to transform our living bodies back into the non-human realm from which they initially emerged.

2

Make note of when you feel anxious or afraid. Next, write down any of the times you can remember deciding not to do something because you were afraid or anxious. Write down instances even if you aren’t sure about whether or not the emotions were necessarily related in any way to death or dying.

3

Compare your anxiety with thoughts of death. After you have one list of thoughts of death and one list of anxious moments, look for commonalities between the two. For example, you might notice that every time you see a particular brand of candy you feel some degree of anxiety, but you’re not sure why. Then you realize that you think about death during these same situations. You might remember that the brand of candy in question was served at your grandparent’s funeral. Then you also began feeling some degree of fear at the thought of death in general.

  • Such connections, between objects, emotions, and situations, can be quite subtle, sometimes even more so than the scenario described above. But writing them down can be a great way to start becoming more aware of them. Then you can better influence how you manage the way you’re affected in such moments.

4

Recognize the link between anxiety and anticipation. Fear is a potent force that can potentially influence just about anything you do. If you can start to look beyond your fear, you may find that the actual event you’re dreading is not as terrible as think it is. Anxiety is usually wrapped up in anticipation about how things will or won’t go. It is an emotion that looks to the future. Keep reminding yourself that fear of death is sometimes worse than death itself. Who knows, your death may not be as unpleasant as you imagine it to be.[7]

5

Be honest with yourself. Be completely honest and fully face the fact of your own mortality. It will eat away at you until you do. Life becomes much more valuable when its temporarily is realized. You know that you will face death sometime, but you don’t have to live life in fear. When you are honest with yourself and face your fear head-on, you will be able to start deconstructing this phobia.

Complete Article HERE!