Go gently into the night

SA-trained medics share personal experiences of assisted dying in Canada, writes Claire Keeton

● Occasionally a French mastiff accompanies Dr Dirk Coetsee when he supports people choosing “to end their suffering on their own terms” through assisted dying, which is legal in Canada, where he works.

“I have supported over 800 patients to go ahead,” says the family physician with gentle eyes who delivers medication to them through an IV drip, often with family present. A Stellenbosch University graduate, he works with the Medical Assistance in Dying (MAiD) programme under Vancouver Coastal Health.

By April, DignitySA plans to lodge a case for the right of terminally ill South Africans to choose a dignified death — a cause supported by moral icons such as Archbishop Desmond Tutu — in the North Gauteng High Court, said the group’s co-founder, Stellenbosch University philosophy professor Willem Landman.

In a lecture at the UCT summer school on Friday, emeritus professor of medicine JP van Niekerk said: “Assisted dying is one of the great moral revolutions whose time has come, like the abolition of slavery and women’s and gay rights. If you don’t agree with it then don’t do it, but give people the choice.”

‘I should have done this five years ago’

For his part, Coetsee said his experiences as part of MAiD have been overwhelmingly positive. He recalled an occasion when the French mastiff, Wagyu, came with him to a hospice to comfort a former dog trainer who had decided to end her life.

“When we entered the room, Wagyu got on the bed next to my patient, calming her nerves almost immediately. As I administered the first medication intravenously and my patient’s breathing became shallower, Wagyu moved from her legs to up beside her.

“Wagyu sniffed her face as she stopped breathing and gently placed her head on the lady’s chest. She stayed in this position until the lady’s heart stopped. She then moved from the bed onto a chair behind me, looking out the window. Everyone, including experienced hospice staff, was moved by this unique interaction.”

At other times, the mood can be lighthearted, said Coetsee, who brings a Bluetooth speaker for patients who want music. One woman’s playlist included the Willie Nelson song Roll Me Up (and Smoke Me When I Die).

Another South African-trained GP said 14 of his patients had chosen the MAiD route. Some ask him to be there at the end, though he does not get involved in the procedure.

One lucid 92-year-old told him on her deathbed: “I should have done this five years ago. I haven’t been enjoying anything.”

The GP said this woman “had the songs she wanted from Newfoundland playing and waved goodbye to us. She was clear-headed and intelligent and knew what she wanted. When the doctor asked: ‘Do you know what I am here for?’, she said, ‘Yes I understand.’ When he asked, ‘Should I go ahead?’, she said, ‘Yes, go ahead.’”

A 105-year-old patient told him “nobody should have to live this long”.

Coetsee said sometimes relatives urge a person to delay death, perhaps to reach a milestone birthday, but “when you are suffering every day, turning 100 does not matter any more”.

“Often people will go ahead on their birthday or an anniversary. One lady chose to go on her wedding anniversary.”

Unslippery slope

Those who oppose assisted dying often cite religious beliefs, concerns about abuse and the fear that it is a legal slippery slope to wider adoption of euthanasia.

In the UK, more than two-thirds of those who support assisted dying identify as Christian, said Van Niekerk, who succeeded Tutu as a patron of St Luke’s Combined Hospices. Beliefs should not influence constitutional rights, the razor-sharp Van Niekerk, 88, said in an interview at his Cape Town home.

Evidence from many countries — about a dozen nations have assisted dying legislation — showed concerns about abuse or a “slippery slope” were unfounded, he said.

Sean O’Connor, host of the podcast How to Die and a Death Café founder, echoed that: “There is no evidence that the safeguards are abused. This is about autonomy, which is why some people fear that consent is an issue. But that’s our duty, to put those safeguards in place which work all over the world.” he said.

Palliative care & assisted dying can coexist

In South Africa, some palliative care practitioners — whose work eases the ordeals of patients facing life-threatening or terminal illnesses — oppose assisted dying, arguing that it would not be necessary if quality palliative care was more widely available. But only about one in seven South

Africans (14%) can access palliative care and pain control, a similar proportion to World Health Organisation estimates globally.

Prof Rene Krause, head of UCT’s interdisciplinary palliative care and medicine division, said: “Access to palliative care remains severely limited in both public and private sectors. I am worried that the current focus on assisted dying, which is a complex and controversial issue, detracts from the critical issue of inadequate access to palliative care.”

UCT neuroscientist prof Joseph Raimondo said palliative care and assisted dying are about supporting dignity at the end of life and can exist together. “If you have access to palliative care the chances are you will have a beautiful death,” he said, but sometimes it is not enough.

Palliative care, like all medical interventions, can fail, Van Niekerk said in his lecture.

“Palliative care and assisted dying are not mutually exclusive, assisted dying being another stage of total care.”

Comforting option ‘a phone call away’

Coetsee and his compatriot Sean Davison are among those who have found that their patients find it reassuring just to have the option of assisted death. “Only about 50%-60% of those who are eligible for MAiD go ahead, but patients have said it is very comforting that it is one phone call away. This helps to give people a sense of control at a time when so much else is outside of their control,” Coetsee said.

The median age of people choosing MAiD is 77.6 and the majority are patients with cancer, according to the Fifth Annual Report on Medical Assistance in Dying in Canada, 2023. About half the deaths took place at home, about a quarter in long-term care facilities and the rest in hospice or acute-care facilities.

Coetsee said a colleague had had a 91-year-old patient with congestive heart failure and distressing breathlessness. “She used to volunteer on the palliative care ward, which strengthened her conviction about MAiD.”

This woman told her doctor, “I’m not scared of dying but I’m scared of getting there. MAiD is the ultimate act of compassion from one human to another.”

Coetsee said the woman’s belief that it is the suffering leading up to death that is the frightening part, rather than death itself, was widespread. “Often people feel that they cannot continue the way they are living and MAiD is a last resort.”

Alleviating suffering is among the reasons for supporting assisted dying. “We never give up on relieving suffering during life, and no-one should die with unbearable and intractable physical or mental suffering. However, this should only be done with legal means and be appropriate to the needs and preferences of the dying,” Van Niekerk said in his lecture.

More than 80% of people receiving assisted dying “cited the most common physical and psychological suffering was the loss of ability to engage in meaningful activities and the loss of ability to perform activities of daily living”, he said.

‘What kind of death do you want?’

Davison has been convicted of breaking the law in both New Zealand and South Africa for assisting people — including his mother, an 85-year-old medical doctor who had cancer — in their desire to die to end their suffering. In July last year he was arrested in the UK after he helped a woman make arrangements to go to a euthanasia clinic in Switzerland.

O’Connor noted that some people were able to swallow the drug that would kill them by themselves, but others needed a practitioner to help administer the drugs. “Some people can’t do it alone and they need help. So we need to decriminalise that.”

DignitySA is asking the Pretoria court “to declare the blanket prohibition of assisted dying unconstitutional, thus decriminalising it, and to instruct parliament to pass a law legalising assisted dying”, said Landman.

Coetsee’s involvement with assisted dying was sparked by a close friend in South Africa who had cancer. “While my friend could not access assisted dying, I realised I could help people here [in Canada]. I’ve provided MAiD to patients who lived in a mansion and had a butler prepare their meals, to patients living in social housing who don’t have the resources to pay for their own funeral arrangements. This role has reminded me that death is the one thing that is waiting for us all,” he said.

O’Connor asks: “What kind of death do you want to have? What do you want for your parents? Most of us think we’ll die well but that’s not likely to be the case ... Assisted dying is about mercy. It’s about empathy and freedom of choice.”

This role has reminded me that death is the one thing that is waiting for us all Dr Dirk Coetsee