TORONTO -- Provincial and territorial death certificates should indicate when a patient's life was ended with the help of a doctor, says an analysis published Monday in the Canadian Medical Association Journal.
Jocelyn Downie, a professor of law at Dalhousie University in Halifax, said most provinces and territories require that the immediate cause of death, as well as underlying and other causes, be stated on certificates.
In cases in which a doctor has agreed to a request to hasten death for a patient with a "grievous and irremediable" medical condition, assisted death should be included as one of the causes, Downie argues.
"I think that the disease that qualifies you for the physician-assisted death should be recorded as the underlying cause of the death and then the actual injection or ingestion (of lethal drugs) should be an antecedent (prior) cause and then the actual physical event should be the immediate cause of death," she said, referring to a patient's heart stopping.
The underlying cause of death needs to be recorded for national mortality data, she said. "It's really important that we keep track of how many people are dying of cancer or because of ALS or multiple sclerosis, so we can make our (resource) allocation decisions for research and health services appropriately.
"It all needs to be there on the death certificate -- both the disease that qualified you for the physician-assisted death and the fact of it being an assisted death because we don't want to lose track of either."
Downie and co-author Kacie Oliver write in the CMAJ that it's critical that a physician's role in a patient's demise be recorded so national statistics can be collected to ensure the procedure is being performed as intended under the Supreme Court of Canada ruling last February.
That ruling overturned the ban on physician-assisted death, either through a prescription for fatal medications which a patient takes themselves, or euthanasia by lethal injection administered by a doctor.
The high court stayed its decision for a year to give Parliament time to draft new legislation and regulations, which would make assisted death legal this February. However the Liberal government has asked for a six-month extension on that timetable.
Recording a doctor's role in a patient's death is "important so that we can do research and understand what's going on with assisted dying," said Downie. "It's also a direct tool of oversight so we can do a check to know when is this happening and is it happening properly.
"And a fundamental reason for wanting to know that is we want to both ensure that our law and policy is correct, but also so people can have trust in the system," she said.
"We need transparency in order that people who are concerned about assisted dying can be reassured -- and we all can know -- that in fact it's being done properly, that it's being done for those who qualify and it's not being done for those who don't qualify."
The issue of listing a doctor's assistance in dying as a cause of death has caused a great deal of discussion among members of the Canadian Medical Association, said Dr. Jeff Blackmer, vice-president of professionalism at the 81,000-strong organization. (The CMAJ is editorially independent from the CMA.)
"What the CMA has recommended is that this be clarified in any legislation or regulations that comes forward and we haven't landed on a recommendation of our own," said Blackmer, noting that the causal content on death certificates was discussed among delegates at the CMA's annual meeting in Halifax in August "and there were strong feelings on both sides of the issue."
"I guess there was a feeling that there may be some advantages to listing assisted dying in terms of honesty and clarity and tracking and reporting," he said. "But then there were other people who noted issues -- and I think they're legitimate issues -- around things like privacy and confidentiality."
Downie said there should be provisions in regulations governing death certificates that would not allow for public disclosure of assisted death to protect both the patients who requested the procedure and the physicians who delivered the service.
