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Assisted Dying in Canada with Stefanie Green, MD

Stefanie Green, MD, was one of the first providers of Medical Assistance in Dying (MAID) in Canada, when it became legal in 2016. Her book, This Is Assisted Dying: A Doctor's Story of Empowering Patients at the End of Life, chronicles her first year working in the field of MAID. In our conversation, Stefanie reflects on what has changed in her work in the past eight years, the people she’s met and how she created a national organization for physicians working in this field. She also shares how this work has shaped her own life and thoughts about death.


You can learn more about Stefanie’s work and her book at https://www.stefaniegreen.com/


Transcript:

[00:00:00] Sarah Cavanaugh: If you like Peaceful Exit, you might also be interested in The Heart of Hospice. The host, Helen Bauer, who is a really thoughtful, amazing human, she interviews a wide range of experts about end of life care. It's come up again and again in my work that people don't really know what hospice is. They wait until the eleventh hour to call because they don't know the critical role that this care can play, and there's a real fear there, um, as if hospice is the absolute end. 

So, Helen's work explaining and examining end of life care is really, really important. If you're a patient, caregiver, anyone working with hospice team, this podcast is for you. You can learn about hospice basics, advanced care planning, patient and caregiver advocacy, grief and bereavement care, and so many resources for caregivers. 

I just had the pleasure of being on the Heart of Hospice podcast and Helen and I talked about my personal experiences that put me on this path and Why we need to access our full range of emotions, especially while grieving. We also connected on how did we find joy and humor and lightness in talking about death, because it feels pretty dark sometimes, but not always. 

But there's lots of great episodes, so go check it out.  

Sarah Cavanaugh: Hi, I'm Sarah Cavanaugh, and this is Peaceful Exit. Every episode we explore death, dying, and grief through stories by authors familiar with the topic. Writers are our translators. They take what is inexpressible, impossible to explain, and they translate it into words on a page. 

My guest today is Stefanie Green. She's a practicing physician in Canada. She was one of the first providers of MAID. That stands for Medical Assistance in Dying. MAID. became legal in Canada in 2016. Her book, This Is Assisted Dying, a doctor's story of empowering patients at the end of life. Chronicles her first year working in the field of MAID. 

Stefanie and I talk about how she switched from maternity care to end of life work. How both are deliveries in a way, delivering babies and then delivering people at the end of their lives. So what is next? We talk about what this field of practice looked like in 2016 and how it evolved since. And we talk about the people she's met, and how she created a national organization for physicians working in this field, and how this work has shaped her own life. 

Welcome to Peaceful Exit. Thanks for having me. I loved your book. Oh, nice. Because this subject is very new to me. So let's dive in. I am so fascinated by your decision to go from birth and maternity to death care. And you use the word deliveries.  

[00:02:56] Stefanie Green: Yes, I think it's fitting for both, actually. I really feel incredibly grateful for my career in maternity care. 

I think it really prepared me well for my work in assisted dying at the other end of life. And I'm constantly seeing the similarities in the skill set that's required as a professional to do this work. The transitions, I think the deliveries, I think the events themselves, they have a real strong similarity to what I'm supposed to do, you know, to manage them, to be that knowledgeable guide for people, to help them through this natural process. 

There's a lot of emotion, there's a lot of intensity, there's a lot of family dynamics. It seems clear to me that I'm not the most important person in the room when this is all happening. And these intimate moments are unfolding. And it's for me to guide and then to respectfully withdraw at a certain point as well. 

There's a real art to the choreography that's involved in doing that work. And so I feel exceptionally lucky.  

[00:03:52] Sarah Cavanaugh: Well, and you're a pioneer because you were right at the beginning.  

Stefanie Green: Yes, for all the good and bad that that brings.  

Sarah Cavanaugh: Yeah, that resonated with me because I love the startup phase of anything, regardless of what it is. 

I love that generative phase of things. Yeah. Well, let's talk a minute about language. I often talk about how important language is around end of life, especially in an issue where language could be weaponized. The title of your book is, this is Assisted Dying, and Canada. You call it medical aid in dying or MAID. 

Is there a language we should use or is there a language we should stay away from? I noticed in your book you used procedure, provision, physician assisted suicide, euthanasia, transition. There's so many words, so much language around this. How should we talk about this in the U. S.? Because since I'm in Seattle and I'm very curious about how we can talk about this. 

[00:04:51] Stefanie Green: Depending on what you read about it. What you hear, what year it was published or who's saying it. There is a tremendous amount of terminology out there about this topic, and I think it can be confusing and I, I mean, to be honest, I think it can be fearmongering, it can be used and weaponized, as you say, words are very powerful, so I try to be careful about what terms I'm using. 

I do think it's appropriate to use the terms that are appropriate in whatever jurisdiction you're in so people know what you're talking about. The most common terms that we use in North America. Certainly in the United States, we still hear a lot of people talking about assisted suicide or physician assisted suicide, which is a term I think that's maybe on its way out, or people would like to see on its way out, but it's still the most common term that's heard. 

And it carries some stigma with it because it has the word suicide in it, which traditionally used to be a crime and has a certain aura around it. So perhaps it's still sometimes used by opponents to Either overtly or covertly bring that stigma to the conversation. So it's not a term I tend to use, but when people talk about assisted suicide, what they're tending to mean or tending to refer to is a self-administered death, a self-administered event where a physician or nurse practitioner, depending what jurisdiction you're in, has provided the medication to the patient who then self-administers that medication and then it causes their death. 

The other term that tends to be used is euthanasia, and it's the most common term and the preferred term in Europe, actually, when talking about assisted dying, so still very prevalent, and it typically refers to when the clinician administers the medication. So really the only difference between them is who gives the medication to the patient. 

I think in Canada, we specifically didn't use either term. We talk about medical assistance in dying. I wasn't at the table when someone chose the terminology, but I imagine the word medical is there because it's a nod to the fact that there's a clinician involved. It's either a medical doctor or a nurse practitioner, and that's an important part of this program. 

It's helpful not to use the other terms that are laden with other references. We talked about assisted suicide, I think euthanasia can dredge up some history as well, especially from Europe in the Second World War where it was used as a euphemism for something completely different. And it tends to taint the conversation. 

So we talk about medical assistance in dying and it's an umbrella term in Canada. We actually are one of the few countries in the world that has both options of clinician administered or patient self-administered assisted dying. And myself, when I'm in Canada, I talk about Mead. It's a lot easier to say. 

It rolls off the tongue quicker than medical assistance in dying. But I also tend to use the term assisted dying. That's the generic term for any of this care in any jurisdiction, whatever rules or regulations are around it, no matter who's administering it, no matter what the exact legislation says, we're talking about assisted dying. 

And so for me, that's the term I tend to use the most. And that's why I wanted that term. If possible, in the title of the book, because we're talking about assisted dying, however it looks in the jurisdiction you're in, we're talking about the same topic.  

[00:08:03] Sarah Cavanaugh: I really appreciate the directness of your title. You know, this is what it's about.  

[00:08:09] Stefanie Green: Titling the book was probably the hardest part of the process and it was the last thing we settled on. Goes to the heart of why this book was written and what it's meant to portray and so many feelings that people bring to the topic. And in the end, I'm really glad it was just simple and clean and to the point because I wanted to say, what is this is to done? 

What is it? How does it work? How does it feel? What do people say? How does that make me feel when I hear them say it? What is this and what isn't this?  

[00:08:43] Sarah Cavanaugh: Yeah, I appreciate that. And I also, I'm always looking for what creates peace in people's lives at the end of their lives. And I was struck by not only the medical assistance itself, but it was even when they were eligible. 

[00:08:57] Stefanie Green: That has been one of the earliest. Discoveries for me in doing this work, it's so striking. I don't think I saw that coming. And to this day, after almost eight years now of doing this work, I'm consistently seeing the same type of reaction. Most of my work is not the actual event itself, right? Most of my work is in getting to know someone, getting to know what's important to them, trying to understand or have them express to me. 

Why they've come to see me. I know they've come to see me because they're asking for an assisted death, but why now? What's changed? What was meaningful before that they feel that they've lost? Is there a way to bring that into their life again or reinvigorate that? Why do they believe they're suffering? 

Suffering from what? Could we find other resources? That whole conversation, that whole exploration is part of my assessment of whether they're eligible for this care. And that's really the. bulk of my work. And of course, all of that conversation. has nothing to do so much directly with their death. That's really about how they live, how they lived, what was important to them while they were living, while they're living. 

And so that was interesting to me. And so of course it leads to this artificial conclusion. At some point I'll sit down in front of someone and possibly after that whole rigorous assessment, I might be able to say, you are eligible for this care. And that statement, I've always seen, is very empowering to patients. 

It's something they've been wanting to hear from me. People come quite nervous, almost like they have to do a test and pass. And when I finally have the opportunity to say to them, I think you're eligible for this care, that doesn't mean you're going to have an assisted death, that you have to, but you can if you truly feel it's what you need at a certain point. 

I am consistently struck with the effect of that line. People immediately, change. There's a physical change that I see in them. They relax. Their head starts to nod a little bit. They start to have a little smile on their face. And they almost immediately will follow that with an expression of gratitude for the option, for the fact that we could have these conversations, for the ability to be frank and direct about this time in their life. 

And they immediately shift their focus from how they're going to die what that's going to look like and the fear of that, to how they're going to live the rest of the time they have left. There's an immediate shift and it's striking and it's wonderful and I feel like most of my work is done at that point. 

Of course, there's lots more to do but I feel like that's the bulk of my work. 

[00:11:35] Sarah Cavanaugh: Yeah, that's that moment, that moment when they realize that there might be an end to their suffering.  

[00:11:42] Stefanie Green: Yeah, or that they have a choice in it. These are people who most often feel they've had no control and no ability to say or express what they want. 

This illness generally has usurped that from them for weeks or months or years. They've kind of been helpless in the face of their illness, or they felt that way. And I think this gives them a bit of sense of some ability to make a decision that they have a say over. Yeah, it's empowering.  

[00:12:16] Sarah Cavanaugh: Yeah. I want to continue this thread, but let me circle back to just provide a little context. 

How did the Supreme Court decision in Canada open the door for Maid and for what you are doing?  

[00:12:29] Stefanie Green: So Canada was a little unique at the time in the way it came to assisted dying. This wasn't brought to our country because voters demanded it. This wasn't brought to our country because any government thought it was a good idea. 

This only happened because of constitutional court challenges based on the Canadian Charter of Rights and Freedoms. And patients, families, people felt that their rights were being infringed because they couldn't have this opportunity. And the Supreme Court of Canada eventually agreed with that. And we ended up with a unanimous decision at the Supreme Court saying that certain people in certain situations, if they applied for an assisted death and someone offered it to them, that assistance to die would no longer be considered criminal based on my activity. 

[00:13:22] Sarah Cavanaugh: I was fascinated by how you had to manage sort of not ending up in jail. Like you had to really make sure that you were, you know, not going to jail. 

[00:13:30] Stefanie Green: Not going to jail. Yeah. That's important to me. Um, yes, if I do this wrong, if I don't follow the rules, if I don't follow the law, The punishment for that is up to 14 years in jail. 

In the early days that was very present in our minds. A little less so now because we have a better understanding of the work and how it's done. But it's a daunting reality that's always there, for sure. Yeah. Yeah. So, who is eligible for MADE? So, in Canada, in order to have an assisted death, I like to say there's five things that need to be true. 

It's a little more complicated than that, but the five things that need to be true in every case, no matter what, is that the patient, the person, needs to be over 18 years of age. They need to be an adult. They have to be eligible for Canadian government funded healthcare. They don't have to be a Canadian citizen, but they have to, you know, have status here, refugee, permanent resident, that kind of thing. 

And Canadians living abroad who come home are also eligible for this care. So you can't come from another country and pay enormous amounts of money. It just doesn't work. It's not legal. I don't see that ever changing. The third thing is that a person has to make a voluntary request. It has to be voluntary in nature. 

They can't be coerced into this decision by anyone, by a loved one, by a non loved one. There's no exceptions to that. I need to be convinced it's a voluntary request by the person and they can explain that to me and it's consistent with who they are and what their value system is. The patient needs to have the capacity to make this decision. 

In essence, it means that the person understands what's wrong with them. what their treatment options are, can weigh out those options, ask informed questions, and then articulate their wish. They can give an informed consent. So they have an understanding, a capacity to make this decision at this time about this issue, about assisted dying. 

And the last thing that needs to be true is our law says that the patient needs to have what we call a grievous and irremediable condition. And it's defined in the criminal code of Canada. It means that the patient has three things that are true at the same time. That they have a serious and incurable illness, disease, or disability. 

That they're in what's called an advanced state of decline. in capability or function, and that they're enduring a suffering that they themselves believe is intolerable and that cannot be relieved by any means acceptable to them. So, of course, we can break down every word in all of that, but essentially that's what that means. 

And all of these things need to be true. Every one of these things make up the eligibility criteria. This is not easy. This is not simple. This is not quick. You don't phone my office and ask for me to come over next Thursday at 2. It's a rigorous On top of that, there are other procedural safeguards. 

Forms that need to be signed, dated, witnessed, how long between when events can happen, when consent can be given, what other resources need to be made available. There's a number of procedural safeguards on top of eligibility. And that is purposeful. Very purposeful. There needs to be a balance between respecting an individual's autonomous decision to make a decision about what they want for them and what's important for them. 

And I would say government's responsibility to protect the most vulnerable or the potentially most vulnerable in society. And striking that balance can be challenging. And for all I can say about the good and the bad of Canadian government at various times, the step forward that Canada made was measured and careful and bold. 

[00:17:11] Sarah Cavanaugh: And they pretty much got it right. It's really remarkable. And what I notice is that having a nationwide process is so different than the U. S. where we, it feels like the states are all doing different things and it's really not coordinated and it becomes really contentious.  

[00:17:28] Stefanie Green: Yeah, I think a state-by-state approach might be necessary perhaps. 

Yeah, maybe. But leads to such diversity on so many levels. Not just the law, but on the care and the delivery of it and who does it and how it's accepted and how it's not accepted. I mean, it's difficult. Yeah, yeah. It's not utopia here. I should say we have a federal law. It is in the Criminal Code of Canada. 

It's every inch of every province and territory. It's the same law. We have legalized assisted dying. But healthcare in Canada is actually delivered and administered provincially. So there are differences in how it's rolled out. very much. the forms that are used, the certain extra provisions that some provinces have tried to add on top in terms of necessity, not so much about the law and eligibility, but about how it can be done. 

Some provinces are really well organized. Others are less so. So there are variations. And one of our challenges is to help standardize the level of care across the country, making good improvement.  

[00:18:29] Sarah Cavanaugh: Have you more practitioners now than you did? I mean, we're in 2024. What's changed?  

[00:18:35] Stefanie Green: Well, more is a relative term. 

We have more than we did in 2016. That is for sure. We do not have nearly enough. In the beginning, not so many people knew about assisted dying or knew that it was legal. And we had very few clinicians. In the early days, I would fly to different places in the province of British Columbia to offer this care because there were so few clinicians. 

Now, every community in my province has a clinic. pretty much has someone available or access to someone who can do this care. But the demand for this care has risen significantly year after year as more people become aware of it and understand what it is. And so we are continuously trying to keep up where there were no waiting lists before there are now. 

[00:19:19] Sarah Cavanaugh: Yeah.  

[00:19:19] Stefanie Green: So we have more but not nearly enough.  

[00:19:22] Sarah Cavanaugh: Well, now that you know I love words, I'm really curious about this nuance between pain and suffering. Oh, I love that.  

[00:19:32] Stefanie Green: I learned that in my years in maternity care. There is an important difference between pain and suffering, in my opinion. Pain is the experience of something. 

If I line up five people in front of me and pinch each one of them with my fingers, they're each going to experience the same pain, the pinch itself. But the suffering that each person experiences can be completely different because suffering is the story we make up about the pain that we feel. And one person might say, that's weird. 

I don't know why Stefanie just pinched me, and go about their day. And somebody else might freak out about the fact that I came and pinched them. Why did she do that? That hurt me. Is she going to do that again? Is she going to do an instrument? She might make me bleed. I don't know who this crazy woman is. 

That story will cause more suffering in the second person than the first. And so suffering is so individual based on our history, our experiences, the different things we've experienced in our life and how we interpret what comes at us. It's an aspect of our law actually that I really respect and that the criterion of suffering is one of the only criterions that the clinician doesn't decide upon. 

I decide on whether all those other eligibility criteria are there, but the law recognizes that suffering is a subjective experience of a person who will tell me if they're suffering. Because it's not for me to say if you're suffering or how much of that suffering you can endure, before it becomes intolerable. 

I've often seen similar people in similar circumstances. You know, 80 year old woman with the same cancer diagnosis at the same stage, both of them quite fed up and ready to go and calling me for help, um, found eligible. One might say, I'm ready, please come over next Thursday at 3 a. m. I'm done. I need to go. 

And the other one would like to say that and say, well, I feel like I'm ready. I would really like to go next Thursday at three, but I am expecting a great grandchild, my first, and they're due to be born in three weeks. And I want to hold that baby for an hour and then I'm going to be ready. I will tolerate this until then. 

So again, very, very personal. No one else can determine that for someone. I really love that the law allows for that. And I think it's essential that it does. How could it be otherwise? How could I say when someone is suffering and tolerant? They have to tell me and explain it to me.  

[00:22:03] Sarah Cavanaugh: What is your story around death? 

Like, what is your history? And it feels like as you're writing about this, that you're very comfortable with this work. Of course, it probably took an adjustment period.  

[00:22:15] Stefanie Green: I grew up without experiencing much death. I think many of us in North America are quite removed from death and dying. Many of us don't see death in the community anymore. 

We don't live with extended families the way we used to. We don't have death in the home the way we used to. I'm talking about 100 years ago when that was just the way it was. And modern medicine has been phenomenal for so many things. Incredibly grateful for the advances, but it did take both birth and death out of the home, moved them into the hospital setting, and by so doing, made us very unfamiliar with both processes. 

And around death and dying, that kind of unfamiliarity, of course, makes us fearful and ignorant of what really happens and how we become quite scared of that. For me personally, most of my experience of death has been through my work. I became a physician quite young and in the line of work I saw that in my training. 

I saw that in my work in maternity very rarely, but with great impression. A very powerful story that obviously I will never forget. A couple that I work with who are experiencing a tremendous loss, one that Thankfully, few people are forced to experience the loss of an unborn child and their grace and their ability to walk through that experience and to be with them during that time was something I'll never forget. 

[00:23:42] Sarah Cavanaugh: It was incredible when you, when you write about that story that the, you know, at first people hesitate to hold the baby. I think it was the husband that was hesitating to hold the baby and then, eventually.  

[00:23:54] Stefanie Green: Yeah, he didn't even want to look at first. 

[00:23:54] Sarah Cavanaugh: Yeah, and you, you write about that beautifully, because, the story of him then holding her. 

 

[00:24:03] Stefanie Green: And yeah, people change. I see that when they're dying, they tell me, well, I can't wipe my ass. I'm done. And then of course they get to a stage where they found all kinds of inner resources. They never knew they had, they find ways to cope. They start accepting help from loved ones and they end up going a lot further along that route than they thought they were going to be able to. 

And some don't even choose to have the assisted death they swore they were going to have, because they find ways to cope and they find the supports they need and the care that's there and they never actually end up suffering intolerably, right? So, um, yeah, his transformation was relatively quick, that guy. 

[00:24:37] Sarah Cavanaugh: Yeah, I mean, the way you talk about her being born and, you know, accepting her death on the same day, it's just, it's fairly profound. Yeah. How do you set boundaries for yourself so the intensity of the work doesn't overwhelm you?  

[00:24:52] Stefanie Green: Yeah, I am pretty careful with boundaries. I went into this work knowing I wanted to do it publicly. 

I thought and I continue to feel this work should not be done behind closed doors. This is legal, covered medical practice in this country, should be seen as such, should be explained as such, and should be experienced as such. And the only way to help facilitate that is to talk about it and to not shy away from it and don't whisper it in the corners. 

So that's the purposeful boundary I left a little bit loose. In terms of the intensity of the work, I've learned through the years of parenting that you have to make Decisions about when you parent and when you can be at work and how to try to balance that. It's an ongoing challenge for every person I know who has children and relationships they want to value. 

And so I learned that I would not be doing this work on weekends or after 5 p.m. That I was going to protect that time. And by doing so, I could really give myself to the work at other times. And so to this day, I still do that. And I discuss it with my patients the very first time I meet them. And they have great respect for that boundary that I set up front and they all understand, and I've never had blowback about that. 

And that's where they kept me sane. And I have a very supportive partner I can speak to, and one or two close friends. What I really have are incredibly close colleagues across the country who've banded together to create a community of practice, and we support each other in a very grassroots way, talk about what we've experienced and what we've learned, and have you ever seen this, and have you ever seen that, and what did you do in this situation, and by the way, how did it make you feel when X, Y, or Z? 

[00:26:33] Sarah Cavanaugh: Yeah, I really appreciate the authenticity of your group, that they're able to say, this is a human experience and you might feel something when you're actually in the work and it's all new and you're trying to figure it out. Because you could be really isolated in this work.  

[00:26:48] Stefanie Green: When I went into assisted dying, I was determined not to let that happen in my work, nor to my colleagues who were cautiously stepping in. 

I would say bravely, across the country and often in a very isolated manner, there might be one person in a community who would be willing to do this work and they didn't want their colleagues to know they were doing it. They might be in a small town and didn't want everyone at the school to know, you know, they didn't want their children to have to deal with comments from the other children. 

There was a lot of fear at the beginning, and I really thought, wow, we need to support each other. People can't be that isolated. They'll never continue. That's not healthy. And so, along with a small group of colleagues, we founded the organization to support each other. 

[00:27:28] Sarah Cavanaugh: What do you want other doctors to know if they're considering this in their, in their practices? 

[00:27:36] Stefanie Green: I want them to know it's not morbid. I want them to know it's not overwhelmingly sad. Parts of it are. To be frank, I think this is incredibly privileged work. It really reminds me why people go into healthcare. People come when they're most vulnerable seeking care. They are often desperate, often at their worst, and I feel like I have been given an opportunity, been placed in a position by whatever means society has granted me as to be the person they come to. 

What a privileged position that is to be able to help them, to be able to walk with them during this time, to help facilitate their final wishes. This work is profoundly meaningful. I want other clinicians to know that. It's not a bowl of cherries. It is not simple, but it is meaningful. And I think some of my colleagues have lost that in their work in medicine today. 

I know a lot of unhappy doctors. I know people who are bitter about the system. Systems in both of our countries are strained and stressed in different ways. This is an opportunity to help people. And if that's meaningful to you, then this work could be meaningful to you.  

[00:29:00] Sarah Cavanaugh: Beautifully said. How do you talk to your kids about your work? 

[00:29:07] Stefanie Green: I talk to my kids the same way I talk to others, very frankly. When I began this work, they were already teenagers. So in high school or close to it. And. I could have relatively adult conversations with them, you know, age appropriate about what I was going to do. I actually spoke to my family, my kids and my partner about wanting to do this work and what that would mean for the family and how did they feel about that. 

I wasn't exactly giving them veto power, but it was important for me that they understood and that they would be supportive because it would have been really hard to do without that. So I answered all their questions. I told them what I was going to be doing, why I thought it was important and how I thought I could help. 

And they were immediately supportive, I'm happy to say. And they are, I don't know if I can even say that out loud, I feel so strange to say, I think they're proud of me. So, uh, I feel wonderful about that.  

[00:30:01] Sarah Cavanaugh: Well, you're doing meaningful work, and I think that's something to be proud of. Thank you. So, everyone has their own personal tipping point, like when things are too much. 

Mm hmm. And I'm curious, how does this work with dementia? You talk a little bit in the book about there's no legal way to have an advance charge for assisted dying. How do you manage dementia in your practice, or do you not see it, or? Mm hmm.  

[00:30:29] Stefanie Green: So things have evolved a little bit. My book was really about the very first year and in the first year I'd not yet seen anyone with dementia come to me asking for assisted dying. 

Since that time that's changed. Um, and it's true we don't have advanced requests for assisted dying, but that's a very specific thing. We also don't have exclusion of certain people or patient populations based on diagnosis. It does not say anywhere if you have dementia you can't have assisted dying, but you have to meet all the eligibility criteria, and that's the tricky part. 

And that's tricky for everyone, but for someone with dementia, the tension is in the requirement to be both in an advanced state of decline in capability, which refers to a cognitive decline in someone with dementia, and at the same time, you still have to have capacity to make this decision. So how could those two things ever be true was the dilemma. 

And continues to be the dilemma. It turns out there are ways that people can meet both of those criteria. Not all patients, but some. And we have learned that from colleagues in other jurisdictions around the world, how they do this work. And we've borrowed from them. And I have absolutely helped a number of people with dementia to receive an assisted death.  

So I think it's important to say that people with dementia can access assisted dying in Canada. They have, they do, they will continue to, but it's complicated. It's complex and not all patients will be able to be found eligible. But I should say. that what Canadians have made very clear and what many people in North America have made very clear is that they would very much like the ability to make an advanced request for a maid. 

So an advanced request, what I mean is that they're making a request for an assisted death before they meet the eligibility criteria. Maybe someone who's been diagnosed with Alzheimer's, who's already symptomatic and struggling, but still functional enough to be at home and dealing with their diagnosis and kind of grappling with what's coming ahead, they might wish to say when A and B and C are true, I would prefer to have an assisted death because I want to avoid the late-stage ravages of this disease. 

And that's not currently available or legal in Canada, but we have had consistent polling showing a tremendous amount of support for that. So I think it's a matter of when, not if. We actually have one province, the province of Quebec, that actually legislated the ability to have an assisted death by advance request. 

They've given themselves two years. So by June of 2025, that will be legal and functional and actionable in the province of Quebec. And I think that will create a certain amount of pressure on our federal government to deal with that in one way or another to perhaps harmonize that across the country or not. 

Uh, I think it depends on who's in power. So, uh, lots of politics involved in this topic. 

[00:33:20] Sarah Cavanaugh: Yeah, yeah, this is a personal question for me. My father has dementia and Sorry, there was an interesting part of what you were writing about when you talk about is it the first time they forget your name? Or is it the tenth time they forget your name? 

There's so much nuance in when those tipping points happen.  

[00:33:40] Stefanie Green: There's a big difference in an ideology or a legal argument or even a personal plea for care. You know, we want advanced requests for assisted dying. And that's one thing. Operationalizing that into the reality of people's lives is more complicated than people understand. 

That's exactly it. People say, when I don't recognize my family, that's not acceptable to me. But, you know, not the first time they don't recognize you. Right? When is the right time? Not the third time either. Is it a time span? A consistency over time? Loss of capacity is fluctuating. It's not a switch. It's not there one day and gone the next. 

It comes and goes over time. It's hard. Who decides? Who has the responsibility or the power or the accountability to decide when that criteria has been met? You can't ask the family to do that. That's daunting. That, they don't want to be the one to trigger this. That's too much for a family member. And too controversial if they are in his will. 

I mean, there's too much conflict for that. It can't be them. It shouldn't be someone who's never known the patient, who they were before, who they are now. Maybe that's the most objective person, but like, who exactly will make that decision and how will they make it? And do they need the family's permission or not? 

Or who do you listen to? The person who was before that made the advanced request, who had a certain personality and value system? Or the person who's sitting in front of you five years later, who's a completely Different person. Do you owe them more responsibility, or the person you made a promise to five years ago? 

It's it's complicated. It is. It's, it's complicated to operationalize and everyone with acting with the best intention, it can still be complicated. That doesn't mean it can't happen. It does happen in certain jurisdictions and it's done well and it's done rigorously. And I think we can learn from others and, and continue to find ways to do this. 

But there's important discussions that need to happen first. It's not a simple matter.  

[00:35:42] Sarah Cavanaugh: Yeah. I know you live and work in Canada, but have you seen this expanding? globally. What is your sort of take on where we're going with this? I feel like there'll be more pushback in the U. S. maybe than Canada, but I don't know. 

Have there been any, you haven't been sued, I don't think.  

[00:36:02] Stefanie Green: We've actually not had a single criminal charge of any care practitioner in eight years.  

Sarah Cavanaugh: Wow.  

Stefanie Green: A testament to the quality of care that is being provided by an exceptional community of clinicians, she said, noting her colleagues. So no, that hasn't happened yet. 

When I began the work in 2016, there were six countries outside of Canada that had some form of assisted dying available. There are currently, I believe, 16. It changes every year. And there's a variety of forms or limitations on that form of assisted dine in those 16 jurisdictions and the U. S. is one of those within which there are 11 states or District of Columbia that allows assisted dine in some form. 

So I, I definitely see growth in that globally. I think we'll continue to see that. There's many countries who are currently debating it. Why is that? I think it's an interesting question. I think part of it is the baby boomers. Part of it is the population that is entering a stage where they're now 65 and older, who are confronting death, not just their family, but their friends, their peers, their colleagues. 

They see it on the horizon for themselves. Baby boomers have changed every stage of life, their entire lives. How to be children, how to be adolescents, how to speak up, how to marry or not marry, the sexual revolution, how to parent, how to be in the workforce, how not to be in the workforce.  

They've made an impact every step of the way. And I don't see why they wouldn't impact how they choose or want to die or how death and dying looks in their lives. I, I think there will be impact there. That's one piece of this. There's a recognition about death and dying being a part of life and a certain acknowledgement of that and respect of that and maybe discussion about that and wanting Live our lives to the fullest means living our dying days and our death to its fullest and how might that be or how might we want that to be or how might we not want that to be seeing that happen to others in a way that we wouldn't find acceptable or would prefer not to experience. 

So a little bit of the taking back of death and dying. And see what others have done and done carefully and done well, and then saying, Oh, well, maybe this is possible. Maybe we can learn from that and do something similar that fits our culture, our jurisdiction. Yeah, I see continued change.  

[00:38:30] Sarah Cavanaugh: How has this work impacted you in your life? 

And how do you feel about life and death?  

[00:38:36] Stefanie Green: I wasn't really aware of how it was affecting me until I was into it a little bit. It was all so new. But about six months in, I realized more consciously that I was projecting into the scenes that I was witnessing. It was kind of impossible for me not to, and I kind of assumed everybody does this, but I think most people do, but I would see people in a certain situation and I would think, what would I want if that was my diagnosis? 

What would I want at my assisted death. Who would I want standing next to me? Who would I want holding my hand? What music would I want to be playing? Would I want the dog on the bed? Just seeing all the things I was seeing for the first time. And then of course some of the situations it was impossible not to project even more personally into because something about the story reminded me of my life or my family or great aunt Mabel. 

And so it became more personal and I found myself reflecting more and more on questions like that. And so I quickly. I started trying to answer those questions and was brought to reflecting on the relationships in my life. That's really what it all led to for me. You know, do I want a big room full of people? 

Do I want only a few? Who are the people of my life? Why are they the people of my life? Have I told them they're an important person in my life? Have I even spoken to them recently? And reflecting on my relationships has made me put more effort into my relationships and to really value the ones of great value to me and to be more explicit about that and kind of taught me the importance of doing that, which is a little cliche, but it's really true. 

That's really the strongest way this work has affected me. And I think for the better. It certainly made me a better doctor. In my interactions with people in respect of their relationships, I have no doubt it's made me a better person. It's made me a better parent. It's just made me better. And I'm grateful for that. 

It took me a couple of years before I sat down with my husband and said, okay, look, I'm talking about all this stuff all the time. Maybe you and I should talk about this. What would you want? And you know, that's not just a momentary conversation. That's an ongoing conversation that takes time to chip away at and to get serious about. 

So I'm grateful for that as well.  

[00:40:51] Sarah Cavanaugh: Do you feel like you've been able to forgive and resolve sort of difficult relationships?  

[00:40:57] Stefanie Green: It's made me want to for sure. It's made me work on them more. And I actually think the answer is yes. One of the most intriguing things to me about this work, which I haven't had a chance to express to you, but I'd really like to, is that. 

When I started doing the work, I, and today I find myself in these extraordinary circumstances, like things I've never seen, things I've never heard, seeing things unfold in front of me, incredibly sad at times. Often sad because somebody's life is ending, right? So there's a pervasive sadness. Of course, there's loss and grief that's ongoing and anticipatory grief. 

It's sad. But because they know when they're going to die, there's also this opportunity to find some closure, to make effort to find that closure, and even without doing that, Even if that's not happened, which I often see happening, sometimes just in the moment of the event itself, as we're coming up to the final moments of about to give the medication, there's this real paradox. 

It's really evident. There's this incredible sadness, sometimes tragedy when it's a young family. So this sense of sadness, and at the same time, These achingly beautiful moments of people interacting and expressing themselves to each other. The love they have for each other, the gratitude they have for their relationships and what they've brought to each other. 

No one is holding back at these moments. And so the two are happening literally simultaneously. It's quite striking and almost confusing sometimes. And so Beautiful. So when you say, has this work helped me resolve some maybe unfinished business or other anger in relationships? Yeah, I see that closure and the power of that closure and the power of forgiveness and the power of expressing love. 

That doesn't mean I'm going to make nice to all the relationships in my life that didn't go well, but it really makes me want to find some closure where there wasn't any, if that still exists somewhere. Will I be successful in that all the time? No, it's probably a two way street. But for me, I'm going to make the effort to find a more settled place to be. 

Uh, if I can see it not settled.  

[00:43:30] Sarah Cavanaugh: You're reminding me of a moment before my mother died when she met my dad's eyes. I witnessed the love between them in such a palpable way. And the story in your book about the couple that just like were embracing at the end, you know, those moments.  

[00:43:49] Stefanie Green: They are almost impossible to convey the power of those moments. 

Yeah. They are incredibly powerful. And again, like I'm sitting there watching a love story unfold in front of me. Who am I to even be there? I feel a little bit like I'm intruding sometimes. And that powerful moment between people. There's humor. There's anger. There's all kinds of emotions. People are fascinating. 

[00:44:15] Sarah Cavanaugh: They are. And was it Edna, the one that dressed down her nephew? Or was it her grandson? I can't remember. There was a woman who dressed down her grandson. Yes. Yes. Yeah. Yeah.  

[00:44:24] Stefanie Green: Yeah. Why hold back?  

[00:44:26] Sarah Cavanaugh: Yeah. I have about three minutes left. I'm going to tell you what I really think.  

[00:44:32] Stefanie Green: Yeah, exactly. You know, I, I respect that. 

She died with a, you know, not with a heavy heart, but a lighter heart, and she'd set her peace, and she'd been holding it back for a year, so good on her. Oh, wow.  

[00:44:45] Sarah Cavanaugh: So, if you could only tell one story in your book, what story would you tell?  

[00:44:50] Stefanie Green: There's two, really. The first one that I talk about in the book, which was the very first event I went to, is the story of Harvey. 

Um, I will forever be grateful that he was my patient, that family was present with me during that first event because they were extraordinary in their own actions and they had no idea about how to support someone through me. It had never been done on Vancouver Island before and nobody really knows even eight years later, but they were amazingly supportive and I learned so much from them and from Harvey and it was such a beautiful death, if you can say that. 

The other one is the one you mentioned near the end of my book, the story of the couple who are embracing in bed together at the end. There's other stories that I think are funny and important and they taught me other things. I don't know how to answer that. You need to read all of them.  

[00:45:40] Sarah Cavanaugh: You need to read all of them. 

Indeed. I agree. You need to read all of them. Well, one of the things that I'm really exploring with these conversations is what a peaceful exit looks like. And I'd like to ask you, what does a peaceful exit mean to you?  

[00:45:58] Stefanie Green: You know, I still don't have the answer. Um. I think it will depend on the stage of life and the situation, but I think a peaceful exit would probably involve, for me, having a small amount of very important people in my life nearby and a sense of the event itself, whether it's planned or not planned or just happening naturally. 

I think a peaceful exit would be a sense of completion, a sense of knowing it was the end, a sense, not so much of ceremony, but of understanding what's happening, acknowledging it, um, and a little bit of reflecting back and feeling supported. Not so much alone, but being supported in that moment that we recognize together. 

I think that for me would be peaceful, whether there's music or not is a bonus, you know, that kind of thing. I think for me, most importantly, is that I, I recognize what's happening. I'm able to acknowledge it, maybe even not embrace it so much as accept it and feel that, that I've done something, I've touched other lives and some of those lives are with me right there in that moment with me. 

Hmm. That would be peaceful for me.  

[00:47:29] Sarah Cavanaugh: It's lovely. Yeah. Thank you so much for your time today. It was such a pleasure to talk to you and to learn so much about assisted dying. It's a whole new world for me. So thank you. I'm flattered to be here.  

[00:47:43] Stefanie Green: Thanks for your interest in the topic and the opportunity to talk to you about it. 

[00:47:49] Sarah Cavanaugh: Thank you for listening to Peaceful Exit. I'm your host, Sarah Cavanaugh. You can learn more about this podcast at peacefulexit.net, and you can find me on LinkedIn, Facebook, and Instagram @APeacefulExit. If you enjoyed this episode, please let us know. You can rate and review this show on Spotify and Apple Podcasts. 

This episode was produced by the amazing team at Larj Media. You can find them at www.lajmedia.com. The Peaceful Exit Team includes my producer Katy Klein, and editor Corine Kuehlthau. Our sound engineer is Shawn Simmons. Tina Nole is our senior producer, and Syd Gladu provides additional production and social media support. 

Special thanks to Ricardo Russell for the original music throughout this podcast. As always, thanks for listening. I'm Sarah Cavanaugh, and this is Peaceful Exit. 

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