E105 Death, Dying, and MAID in Surgery with Kelly Vogt and Morad Hameed
Listen to this podcast on SoundCloud
Ameer Farooq 00:19
Welcome back to another episode of our companion series. On this episode, we are joined once again by Dr. Kelly Vogt and by Dr. Morad Hameed to discuss death and dying in surgery. We focus our discussion around the topic of medical assistance in dying or MAID, and use that as a focal point to branch out and think further about how we can better prepare patients and their surgeons for discussions around end of life care. We'd love to hear your thoughts. How does MAID get operationalized in your hospital? And how does your surgical service interact with MAID? Email us at [email protected], or tweet at us @CanJSurg.
Kelly Vogt 01:00
So, in 2016, Canadian Parliament enacted legislation Bill C-14 allowing eligible Canadians to request medical assistance in dying. At the time, "eligible" meant you had to be at least 18 years of age, be competent to make that decision, and in fact request it without anybody mentioning it to you basically. Have a grievous and irremediable medical condition with death that is reasonably foreseeable, and again, make your request voluntarily. In September 2019, a charter challenge was launched in Quebec specifically challenging the requirement that death be reasonably foreseeable and the need for final consent for this procedure. This led to proposed amendments to the Criminal Code, Bill C-7, which amongst other things would remove the requirements for death to be reasonably foreseeable and allow a waiver of final consent for patients who may lose capacity before MAID can be performed. Bill C-7 was passed in the House of Commons and is currently being debated in the Senate where it's expected to face many amendments, and in fact, the deadline is today. Before we embark upon this discussion, we want to be clear that we recognize MAID can be very controversial. We respect that there are many differing opinions and viewpoints on this topic but recognize that it's part of our legislation. And we want to specifically explore the intersection between MAID and surgery. We've also purposely not had a discussion about our views on the topic before recording tonight. And just to provide a little bit of context of this discussion, the first annual report on MAID in 2019, was published by Health Canada. And in that year, over 65% of patients who received MAID had a cancer diagnosis as their main underlying diagnosis. About 10% had respiratory, 10% neurologic and 10% cardiovascular conditions. The average age of patients was 75 years and over 80% had received palliative care services as well. The most commonly cited reason for seeking MAID was loss of ability to engage in meaningful life activities, and loss of ability to perform activities of daily living. Of the over 1200 physicians providing MAID in our country at that time, 65% were family physicians, 9% palliative medicine physicians, 5%, anesthesiologists, and surgeons fit in the less than 5% of "other" physicians. Of note, legislation requires a 10-day waiting period between consent and the procedure. However, in 2019, over a third of patients had this window shortened primarily due to provider concerns, they would lose capacity to provide final consent. And so, with that background in mind, I wanted to start by asking each of you where you see MAID fitting into the world of surgical practice. And maybe I'll start with you Chad. With my practice, which, of course, is trauma, and patients like you guys, but also the oncology side of things, I would say that both of those categories are very, very different. And the truth is that many of the pancreatic cancer patients, less of the liver cancer patients, but certainly on the pancreas side, we do have these discussions almost daily in clinic, and sometimes many times a day in clinic. And it's always been interesting as a trainee and then trying to work away on my own with partners initially, the different ways that people frame that topic of dying, the different things that they bring from their own experience and their own belief system into that discussion. As we all know, the ability to steer patients in one direction or the other, potentially in some cases. You know, I can't say that we engage MAID as a formal process very often in the oncology clinic space, but it certainly comes up on a regular basis. So, for that side of things, It's something that I have to address many times a week. On the trauma critical care side, I think it comes up a fair bit less. Certainly, the younger patients, although I think we all see many, many suicide attempts that, in some ways, cloud this or a rationale for some of the concern that comes from opposing views of it, too.
Chad Ball 03:56
I think you made some really interesting points there, particularly around sort of the different scopes of your practice. Maybe Morad, I'll ask your opinion from the trauma and critical care side.
Morad Hameed 05:37
Thanks, Kelly. In trauma, I think MAID never crosses my mind. That's always an acute event. And sometimes we play very long odds, in the expectation and the hope that we can beat those odds. So, I always have a full commitment to survival. In acute care surgery, so it's a similar kind of thing. MAID doesn't cross my mind at all. Occasionally, we do ACS oncology cases. And sometimes this is done with palliative intent, you know for example, like malignant bowel obstruction. But even these patients tend to do well in the short term. And we often hand them back to medical oncology, and eventually palliative care. Where dying becomes more common is in critical care. And, again, you know, the mindset in critical care for most intense visits, I think, is very much of a survival mindset, of resuscitating and being aggressive and asking questions later. Asking these deep existential questions later on. And so, we do tend to play very long odds there and, again, MAID doesn't come up very often. And I think we tend to push the limits in terms of achieving endpoints until the point of utility and utility is becoming, you know, a smaller and smaller area as we have more aggressive means of sustaining life. But eventually, we do hit a point of futility. And usually at that point, MAID doesn't come up either, because patients simply can't live without the most invasive forms of life support. So, Kelly, MAID doesn't cross my mind very often. I do very much believe in patient autonomy and their right to consider that option. But I find it doesn't come up as much in my practice, and I probably do need to think about it more.
Chad Ball 07:47
Maybe for our listeners, I wonder Kelly, Morad and Ameer, if it's worth trying to define or at least giving your impression, the difference between withdrawal of care in a critical care setting and formal MAID in or outside of a critical care setting.
Kelly Vogt 08:03
I think that's a great point, Chad, that probably does deserve some clarification. And for me, in terms of the legislation, I think it's a fairly clean break or easy delineation. And that really is around the ability of the patient themselves, not their family in their stead, but the patient themselves to request voluntarily medical assistance in dying, be able to be competent for that consent, both at the time that they request it and at least 10 days later when the procedure is performed. And to go through with it at that stage. So, for me, when I think of withdrawal of life sustaining therapies, by and large in the critical care setting, what I'm thinking about is the ventilator vasopressors, the types of things that we envision. And in that circumstance, you can easily see how the patient is not able to voluntarily ask for a medical assistance in dying procedure, or able to consent for the consideration of that and ultimately, the procedure. So that's to me where the difference lies. It seems like, from that line of thinking, that those criteria would rarely be all completely met in a critical care setting. I completely agree with you. Chad, do you have any other thoughts?
Chad Ball 09:31
Yeah, no, I think that's great. I think there is some confusion as to what the difference is, so that's perfect. You know, patient consent is one part of it. The other thing I think that I'm sure you'll get into with the current Quebec court challenge, of course, is the root of the underlying issue, the disease or the disability or the limitation or the viewpoint. Is it something that's "fixable"? Is it not? To Morad's point, is it acute or it chronic? Those are the other elements; I think that come into our mindset when we're differentiating the two.
Kelly Vogt 10:10
Yeah, and I completely agree. And I think we will get to that. I'm just curious, before we proceed from Ameer's perspective, given that you trained, at least in part in the time where this legislation came in, I wonder if your perspective is somewhat different than those of us who were already attending surgeons when this legislation passed? Did you encounter this much in your training?
Ameer Farooq 10:31
So I think I'd echo what you have all said: that it has not really come up very much in training that I can recall. And I think it is important to kind of, really dissect some of these terms and forgive the bad pun. But like, I think it is different to think about, you know, end of life discussions versus MAID. Because I think, actually, now, "Being Mortal" was written by Atul Gawande, who's a surgeon. And I think, you know, many of us now recognize how important it is to have these discussions around end-of-life care, what matters to patients, and, you know, sort of what would be meaningful things for them to have and to tailor their therapy accordingly. But it's a very different mindset to actually refer someone to have, you know, medically assisted dying. And I'd argue that it is very antithetical, particularly for surgeons and intensivists, as you pointed out, because, you know, a lot of what we do is trying to do things, you know, when the whole mindset is about fixing people or curing things, it is very difficult to kind of completely change that tack. Not saying that I don't think that there's far more to healing people than steal. But I do think it's a very difficult mental shift that you have to make.
Kelly Vogt 11:56
I really agree with you. And I think what we've sort of touched on but haven't really said is that not only are our definitions, but the legal definition, I think makes it complicated for us to understand and the fact that it's still being debated, and amendments are being tabled. And the legislation is changing, I think makes it a bit of a moving target. And I suspect that at least for myself and other physicians that that has led to some hesitancy in terms of approaching these types of conversations with patients that I've encountered. Do you guys have a formal service in your hospitals for MAID?
Chad Ball 12:35
Yeah, it's interesting and I might push back to with Ameer a little bit, which I know he loves. But yeah, we've referred dozens of patients, dozens, and dozens of patients, through our clinics, again, with pancreas cancer. Some of them are preoperative scenarios where they, you know, they can't be resected. And we don't have a good treatment plan for them. And the medical oncologist can only really offer them quite a limited systemic therapy or no systemic therapy. Those are patients that tend to try and are often asked about it. And then there's the patient that you resect, then that has recurred. That's really no additional options, options other than palliative systemic therapy, as well as palliative chemo. Those patients are another relatively large group that goes. So, you know, there's no question. It depends on the cancer you're dealing with. But we do it a lot. And it fits quite naturally, quite honestly, in the discussion, either upfront or at the back end that you have with these patients over the idea, the concept of dying. I mean, that's probably a whole other discussion and podcast in itself. But I tend to be very blunt about it, I usually say here's the scenario, here's where you're at. And here's what's going to happen, the timeframe of which I can't tell you because I don't have a crystal ball. But here's what it looks like, now, you're going to die of this problem. How do you want to die? Do you want to be at home? Do you know fight it with passion? Are you going to relax about it? I mean, you know, it's striking how different people are, as we all know, from one example to the next. And, you know, it's something I think, and certainly all of us, and surgeons in general don't judge, but it's really essential that we keep that central to our interaction. Because, you know, the reality is we all have friends and family that have died unexpectedly or in a short period of time versus maybe a longer period of time. And I like to sort of think about how we would do that or how we would behave in those scenarios. But until you're in it, you really truly like everything else in life, don't know. And I personally in my life have had people very close to me who I thought would really die calmly and with passion - sorry, with elegance and grace, and went raging into the night. And then vice versa as well. So yeah, I mean, we certainly use it a lot unfortunately. As far as a specific team in Calgary, absolutely, there are a remarkable group of people who are broken down into teams on call, basically. And once that referral is made, patient mentions it, you think it's appropriate, the referral goes out. I don't mean this in a cavalier way, but they sort of swoop in. And they really do take over from that point forward. And I'll just comment that, you know, the individuals at all different job titles within these teams, at least from our observation locally, in Calgary, is that they are absolutely superb at it. And they're very good at differentiating, almost as a psychiatrist sort of, the differences and the drivers of these people and whether it's reasonable or unreasonable, or is it related to something that's temporary, as opposed to truly chronic?
Kelly Vogt 16:00
That's great. Morad, is there a team in Vancouver?
Morad Hameed 16:04
Yeah, Kelly, there's a team in our Health Region, Vancouver Coastal. They put in a lot of thought. And there was a big flurry of activity when it first came out. And now I think there's a fairly standardized pathway for people to consider and request MAID. And I actually encountered this, just thinking a few months ago, I was rounding and we had a patient with a malignant bowel obstruction. And he was still not old. And before we could even discuss his therapeutic options, he requested MAID. And he made a very passionate argument about how he had lived a great life. And he was surrounded by love, and he was ready to call it. And I must say, we were very much still in the intervention and survival surgical mindset. And it was a bit of an uncomfortable standoff for a while. And as a matter of fact, when we rounded, we were actually rounding with one of our senior administrators who was with us for sort of a ride along. And she helped us a lot with navigating the system and talking to him. But it was almost a bit of a... not a confrontation, but opposing viewpoints about the right path forward.
Kelly Vogt 17:29
That's super interesting. Can I push you on that a little bit? What was it that made you uncomfortable about that situation?
Morad Hameed 17:37
You know, I guess I saw somebody who still had a lot of vitality, and somebody who still was communicating well, and who still had family, and reasons to live. And I also saw this as a surgical challenge. He had a locally invasive malignancy, but I thought that it could be resectable. This was, I think, in the context of some end stage liver disease, and I thought that we have the ability not only to resect this, but also to, you know, finesse him through and support his organ systems and maybe achieve some decent length and quality of life. So, I guess I viewed it as a human opportunity, and maybe in some ways, a clinical and technical challenge. And so, my instinct was to try to advise him to engage in the intervention and see how it turns out.
Kelly Vogt 18:42
I think that's so interesting, because I think that a lot of the proponents of medical assistance in dying, really focus on that choice. That idea that, you know, individuals have the right to make a choice what their death looks like, in the time of that death. That is, you know, outside what we, as healthcare providers, suggest to them. And I think that ability, you know, the story you just told really speaks to that conflict that I think a lot of healthcare providers feel when faced with similar situations.
Morad Hameed 19:18
When we met this patient, you know, I had some advanced warning that he was a difficult patient, and he was not wanting to comply with testing and he's requesting MAID and he wanted the form. But he wasn't difficult at all. He was just really thoughtful, and he really wanted to have a say and some control at this stage of his life. So, it was interesting, but the initial perception was he was not complying with the usual course that one would expect.
Kelly Vogt 19:53
As most people who veer off the beaten path typically are called difficult, I'm not terribly surprised to hear that. I wanted to bring it back to emergency surgery and trauma a little bit. It's interesting, one of the first papers that really describe these MAID hospital-based programs describe the program at University Health Network in Toronto. And they specifically discuss some of what we've talked about tonight - discouraging initiation of Made in an actively dying patient, really for fear that it may compromise them to management, since patients may refuse opioids so that they can retain capacity for consent and needlessly consume limited energy and time of patients and their families at the end of their life. And in that paper, they argued that, you know, palliative sedation to alleviate intolerable suffering really is the way to go. And I think, you know, reading between the lines as an emergency surgeon, that really suggests that there's not a tremendous role for MAID in emergency general surgery or trauma care. What I've seen in practice, though, is different. And we actually...well, I'm an author on the paper, but the lead author is our nurse practitioner, and the senior author, one of our critical care physicians, who are presenting our series of MAID in trauma patients, the only one we know of that's published. And the stories of these patients are tremendously interesting, in that these are patients who all voluntarily asked for MAID at varying times after their trauma. And the biggest thing, I think that links them all together, really is their eventual understanding of what their quality of life would be after this acute, tremendous change. And I think the spirit of the charter challenge, and the amendment really relates to the idea that some individuals may actually see MAID as a form of advanced care planning. And that they potentially have a right to make decisions about MAID before their death is reasonably foreseeable. That concept really resonates with me personally. Many people who know me are aware of my beliefs that society would really benefit from a well thought out public education campaign around this concept that everyone actually eventually dies. And in some cases, that's a concept that's difficult to crystallize in another citizen. For example, in the older adult patient who arrived in hospitals with a bowel obstruction, but also with a long list of comorbidities, and self-acknowledged poor quality of life because of them. I think the discussion and decision-making process becomes much easier if you think about it ahead of time. And I wonder if this discussion around MAID might actually be a way that we can encourage those types of discussions to occur. That was a long-winded way of looking for your thoughts on how do we approach the emergency surgical patient who has a terminal diagnosis? And should we be mentioning MAID to them more than we do?
Ameer Farooq 23:09
Yeah, I think those are very interesting questions. I think there's two things I would say. I think that the charter, or the legislation proposed that's going on in Quebec right now, is interesting, because when you change the underlying kind of tenor of this bill, which is that, you know, up until this point, it's been people who have a very foreseeable death. I think that is a sort of a very different question than someone whose death is not imminent, or from our best medical knowledge, isn't very foreseeable. That's a very kind of different, and, to me, a very challenging discussion, because I always think of this New England Journal paper. I think it's the New England journal. Where they looked at quality of life of patients who had a spinal cord injury, like, I think one or two years out, and it's almost identical to their quality of life, or very similar quality of life to what they were like preinjury. And so, I really get a little concerned that people who have mental health issues, were suffering an acute crisis of depression, for example, if they might be, you know, prone to having this sort of, I don't know if abuse is the right word, but perhaps prematurely deciding on this option. I think for acute care, general surgery patients, I think, absolutely, that's something that we need to talk about more and we all can recognize it. We need to do better. I mean, we had a patient not too long ago on the colorectal service, who, unfortunately had a very quick sort of occurrence after an operation for colorectal cancer. And, you know, like she wasn't imminently dying, and we were all sort of stunned when she said, "I want MAID". It just so happened that events transpired that she ended up getting a bowel obstruction, she ended up, you know, having an emergency operation. And then she ended up, you know, needing subsequent emergency operations and passing away anyways. And so, you really, in some ways, I felt quite kind of disturbed or kind of sad about that, because she had sort of indicated that, I don't really want to go through all of this. And yet, you know, it's very hard to turn those wheels, but we need to think about doing that more often. And the second thing is, I just want to say how important it is, I think, for all of us to have these discussions about death. I mean, not to get too philosophical here. But you know that the Stoics, and certainly in the Muslim tradition, there's a long tradition of, you know, talking about death. And we use this word morbid, like, that's a very morbid thing to say. And morbid, you know, literally has to do with death. But I think it's so important for us to enjoy life to actually think about death as an inevitable consequence, and something that we have to face sort of on our own terms. So, I actually love that idea. And I think part of this whole discussion is actually changing the way that we think about an approach and maybe even embrace that. So sorry for such a long-winded answer. But, you know, I feel passionate about both of those points.
Kelly Vogt 26:21
I hear you, I feel passionate about them, too. So, no apologies necessary. Do you think, Chad, that we'll ever get to a time where these conversations, whether you, you know, buy into this concept or not, but these conversations occur with the same frequency in our trauma patients and emergency patients, as they do in your oncology clinic?
Chad Ball 26:44
You know, to answer your initial question, yes, yes and yes. Like, I think you're exactly dead on, we need a large national public advocacy discussion program to talk about dying. And it has to be national, it has to be Canadian made and Canadian delivered, because, of course, I think all of us, at least three out of the four of us have worked for extended periods of time in the US. And the underlying view of things, of this topic in particular is totally different. So, we need a Canadian solution. You know, I get that it's extremely hard to mechanize and to make happen. But it's quite nuts to me that there's never been an attempt, at least I know about to do this. And you look at what's going on around us now with COVID. I mean, just imagine if we had a more reasonable global understanding of the process of dying in this country when COVID hit. Because the reality is, and this may sound harsh, but I think it's probably true. When you look at the behavior of many, many, many people in the community across this country, and certainly even more than the US in terms of not wearing masks, in terms of having house parties, in terms of gathering, all these things that we know are high risk activities, and then filling up our ICUs and filling up our hospital beds with sick COVID patients. And then that leads to as you know, the downstream effects of canceling elective surgeries, canceling non elective urgent cancer surgeries. You know, people do die because of those community decisions. And it's one thing to say, well, you don't have to wear a mask, you can behave as you want. But if you come to the hospital, and you're 85 years old, (I'm just making that number up, of course), then we will not be able to treat you. I mean, that's an extreme tangent on this overall concept. But it seems like it would probably be a lot less of a run or a stretch to get to that more nuanced, real time changing, paradigm shifting changing decision, if we already had a basic level of understanding to your point, and it's clear, we don't right? Like how many patients do we talk to that don't have advanced directives? Haven't thought about this? Haven't discussed this with their family doc, their specialists, their family? It's absolutely, to be honest, the word in my mind anyway, maybe it's overstated to you guys? I don't know. But it's chaos. I agree. We need to have some sort of discussion and campaign nationally.
Kelly Vogt 29:33
I mean, it's tragic. It's so difficult. We've all been there in the middle of the night, having that conversation with a patient if they're able to participate or their family member where death is imminent, and that possibility has never been considered. We are doing a disservice to the patients that we care for their families. I cut you off Ameer - you're up.
Ameer Farooq 29:59
I just want to, you know, push back a little bit in the sense that, you know, Atul Gawande, when I was doing my master's actually came to give us a talk. And he talked a lot about sort of the work that he had done to write "Being Mortal". What struck me, you know, in the usual Atul Gawande fashion, he's come up with a checklist about, you know, having end of life care and published on it, and all those things. But what struck me in the discussion that he brought up is that, you know, much of what we're trying to do here is actually have a culture change on a national level. Like, in what part of our lives do we really even sort of acknowledge our mortality? Like, you know, of our lives are increasingly caught up in, not to go on a very wild tangent, but I think it is germane to the discussion that a lot of our lives are caught up in incredibly superficial things and is exacerbated by social media. So, you know, as much as I love the idea of having a campaign to get people to think about the end-of-life decisions, I really struggle with the thought of how effective that would be. Because essentially, what you're asking people to do, is to consider their mortality. And we all know that Blaise Pascal said that, you know, the most brave thing that someone can do is to sit alone by themselves for an hour and think, in an empty room. And so, you know, part of that is just facing your own mortality. So, I don't know how successful we would be in a campaign like that.
Chad Ball 31:35
Yeah, I mean, I guess I'm more optimistic about people maybe than that, you know. We have strong public advocacy, and prevention programs in injury in particular, across the country and across the world that have huge, massive public health, positive effects and benefits, and they're measured and we know this. I don't personally see why dying is any different. And, you know, we've interviewed Tim Pollack, as you know, he's done a bunch of work on this. And we talked about that in a podcast. And Dr. Gawande, we haven't had on yet. But, you know, there is nuances to this. I don't necessarily think you have to come to a conclusion and be 45 steps into the process of, if I'm dying this way, then this happens that way, then that happens. But I think a baseline small amount of thought into how you want this to look, is no different than planning for your financial future, for your family's future. It should be in the same ballpark discussion. Now, who initiates that? Well, the reality is, it's probably the primary care network and givers, physicians, that probably should be... should is a strong word, but maybe could be more interested in that, despite the pressures that they have in their practices, you know? As Kelly, Morad, and you and I all know, and people listening, you know, at two in the morning, this morning, when I'm having this conversation, on the phone, 12 hours into an admission for acute injury, it's hard, it's a problem. So, even if that family this morning had a little bit of conversation about it, it would have put us in a much better spot. So, I think people are capable of it. I think, you know, to your point, some of it is religious based, some of it is not. But I think we can all do it. And again, it speaks to what that campaign would look like, how it initiates discussion, how it engages people, how it's presented, you know? It's really smart people like Kelly, who probably have a much better idea than myself as to how to deliver that.
Kelly Vogt 33:54
You give me too much credit. I just, I'm the idea of person in this. I'm not unique in coming up with these ideas. But I do agree with you that I think, you know, Canadian citizens have the capacity to do this. And I think some of what's happening with these proposed amendments to the legislation will allow these conversations to happen in a way that isn't entirely tied to a specific event, a trauma or a cancer diagnosis or whatever that is. And I do think that might help us. Morad, we haven't come back to you in a little bit. Wondering your thoughts as we get close to the end.
Morad Hameed 34:31
Yeah, thanks. Thanks, Kelly. I think in any complex situation, it's resolved by considering and balancing different forces and sometimes I think that we as surgeons represent, the surgical mindset represents like a more of a you know, aggressive and life prolonging force in this discussion. And you know, thinking about a couple of patients in recent memory, one with a guy who's 90 years old with a obstructing cancer at his hepatic flexure, who was told a year before that he was not a good candidate for surgery. And he lived on with this in good health. And we encountered him with one instruction completed. And we actually, after a lot of deliberation, and conferring with anesthesia and ICU, we decided to do a right hemicolectomy. And he had another year with his wife and family. And another case we had with a patient with a bowel obstruction, who I was told is not a good candidate for surgery because of dementia and congestive heart failure. Both of these conditions on further review were pretty mild. Patient had a good quality of life and had a single adhesive band at surgery and left the hospital shortly after an operation for that. So, you know, life is so precious. And I think that sometimes the boundaries, and the perceptions of quality of life can shift. And we don't know how that might play out. So I think, you know, despite all of the wisdom in this discussion, I think it still may be important to come at the beginning, at least to represent that surgical mindset, to represent sort of the fact that the idea that we may not know how things will play out. And at these 2am discussions, if we are representing that view, then maybe also say that, maybe it's worth a shot. But if things don't respond as we expect maybe in two or three days, then we can transition to palliation or end of life compassionate care. But I don't know, what do you guys think about that? Like maybe having a sort of an aggressive upfront mindset, but having a discussion about, you know, to change direction quickly if the course isn't playing out as we hoped. And in my opinion, that sort of gives people in their physiology a little bit of the benefit of the doubt, but still introduces this as an outlet. If we find we're not achieving our goals.
Chad Ball 37:26
I think that's a great way to frame it, Morad. And I think that's sort of what we do. And I think that's what you're saying, in a very humble way right? We see these patients all the time. And we say, you need an emergency operation, it's a big deal, you're super sick, you may not be able to get excavated, this is what it's going to mean for you. What do you want to do when you're two or three days in and we're not able to talk and you're on all this life support? What point then do you want to shut it down versus can carry on? And I like to think that a lot of us, no matter what our setting in this country are pretty good at doing that. My experience in the US, and I would bet it echoes yours and Kelly's was not like that. It was sort of pushed to the ends of the earth: spend as much money as you need to, do not stop under any circumstances. And I always felt a little bit foreign in that world and that discussion. Respected it, you know, for sure. But the baseline demeanor seemed to be different amongst physicians and patients in Canada versus the US.
Kelly Vogt 38:35
Chad I completely agree and that, you know, is echoed in my fellowship experience as well. But certainly in my practice, I agree with what both of you said, we do that. And I think the patient who comes in who needs an emergency operation, and we're talking about whether or not they'll be excavated. There's always room for improvement. But I think that by and large, as emergency surgeons, we are used to and relatively comfortable with those conversations. Where I think we have room to grow are the patients who are perhaps slightly less sick, where there is not a clear cut need to do an operation that night, who have a diagnosis that may compound their baseline physiology or medical comorbidities, or whatever it is in their life that's making it difficult for them. And those are the patients where I think we have an opportunity and an obligation to maybe discuss the options, the breadth of options, including proceeding with aggressive surgical management, including palliation, and including medical assistance in dying. I do think we could improve in that realm. Last word to you Ameer.
Ameer Farooq 39:49
Yeah, I think the biggest challenge is always time, both for you and for the patient, right? So it's always ideal when you actually have time to think and to talk with patients and for us as clinicians, I think the hard part sometimes, and I can say particularly as a resident when you have like 100 pages and you know, the next patient and the next patient the next patient sees it's so important to realize to slow yourself down and just realize like: this is actually the moment where you could you could make a difference and this is not just another night for someone. This is really a defining moment in their life and death. You've been listening to Cold Steel, the official podcast of the Canadian Journal of Surgery. If you've liked what you've been listening to, please leave us a review on iTunes. We'd love to hear your comments and feedback. Send us an email at [email protected] or tweet at us Twitter @CanJSurg. Thanks again.