Living at the End of Life: Choices in Death and Dying
As end-of-life needs evolve, so do the care options that can be provided. Given the researched benefits towards mental health, wellbeing, and quality of life, I propose serious consideration for the use of psychedelic-assisted therapy as a new tool to complement current practices under the end-of-life care umbrella.
Medicalized Death
In my experiences working as a registered nurse in the emergency department (ED) and intensive care unit (ICU), I witnessed first-hand the various ways that modern medicine was used to treat advanced illnesses and heal gravest wounds. Advances in science and technology often allowed our healthcare team to bring people back from what seemed like the brink of death and be witnesses to surprising recoveries. On the other hand, I also witnessed difficult situations where I felt that this medicalized approach to death caused distress not only in healthcare providers but also in families and patients.
By way of tubes, medications, and procedures, many aspects of the body can be accessed, monitored and, to a point, controlled. Because modern science has given us (as healthcare workers) the ability to control many bodily functions, I found myself starting to realize that death in these specialized hospital settings can sometimes be seen as a failure; a failure of inability to ‘cure’. I started to understand that this medicalization of death changed the experience of death from being a natural process of life towards being a medical experience. For decades, members engaged in the medical community have noticed that medical care (as it is usually provided in a specialized setting in the hospital) has seemingly overtaken the dying process to the point where death has become understood to be a disease, and dying as a medical condition to be managed (Staudt, 2013).
Since the 1950s in Canada, death has shifted away from being a social and community event to an individual one; and with this shift from home to hospital, many Canadians may not witness death and dying until they are well into their middle age (Arnup, 2013, p. 36). In my years of practicing in these specialized units, I repeatedly found that patients and their families had failed to have conversations about death and dying together. Often, the first time that families and residents had come face to face with the topic was under the severe stress and fear of facing the possibility of imminent death in the hospital. For these families and residents, death was rapidly changed from an abstract to a concrete concept, and they were faced with making extremely difficult decisions under extenuating circumstances. I often found myself thinking, like others in the medical community, that these resulting decisions were made more so based on fear and confusion rather than an empowered and balanced evaluation of values (Hetzler III & Dugdale, 2018).
Despite the availability of many resources (e.g., technology, machines, medications), I felt unable to facilitate a death that people had authentically envisioned for themselves. I wished to be able to help give them the ability to respond with awareness rather than just reacting to circumstances (Maté, 2003). My experiences in treating patients and prolonging people in these final stages of life pushed me towards other solutions and options which I felt could be more attuned to the humanization of death, a quintessential human experience.
A Right to Choose
I applied for a position as a nurse with Medical Assistance In Dying (MAID), a service provided for Canadians experiencing intolerable suffering from a grievous and incurable medical condition who wish to end their life with the help of a physician or nurse practitioner. This role involved meeting patients and families with a team of healthcare professionals, discussing the wishes of the patient and family, and eventually (after going through many levels of eligibility and consent) meeting on a predetermined date where the team inserted an intravenous line and facilitated the patients’ progress through dying and death. As part of a community team, patients were most often met in their homes and sometimes in a healthcare facility. At first, I was nervous about going into people’s homes. I was not used to kneeling on someone’s rug while their dog watched closely from the couch. I felt that I was intruding into a safe haven, but instead, we were often greeted with welcoming gratitude.
With the absolute necessity of safeguards around eligibility and consent, I saw the implementation of MAID in Canada as a reflection of healthcare adapting practices to patient wishes. What I found most fulfilling about my role with MAID was to support decisions where people have charge and authority to make choices that were authentic to and in line with their desires and values. I found this work particularly significant to my own person, and now I am not only interested in the final moments of life, but how and in what way we arrive at that place.
A Right to Multiple Tools
In 2019, 82% of individuals who accessed MAID also received palliative care services (Health Canada, 2020, p. 44), highlighting a continued need for access to multiple tools under the end-of-life care practice umbrella. What I am proposing is the consideration of another treatment option under this care umbrella: psychedelic-assisted therapy.
Where MAID particularly supports patients in terms of their final moments, psychedelic-assisted therapy can attend to how someone arrives at those final moments. Like palliative care, which provides tailored interventions towards psychological, social, emotional, and spiritual support (Health Canada, 2018, p. 62), psychedelic-assisted therapy has shown great potential to effectively address psychological and existential distress for individuals facing life-threatening illness (Rosenbaum et al., 2019).
Psilocybin, found in over 100 species of mushrooms (magic mushrooms), has been at the center of many recent studies researching end-of-life care. Scientifically rigorous studies involving people with cancer-related distress have shown decreases in depressed mood, anxiety, and death anxiety along with increases in perceived quality of life, life meaning, and optimism that persisted for many months after a single dose administration (Johnson & Griffiths, 2017). Participants have also described increased connectedness to family and reconnection to life, a reclaiming of presence, and a quality of transcendence (beyond anxiety, cancer, and death) that led to greater senses of wellbeing and emotional fortitude (Swift et al., 2017). Traditionally, medicines to treat anxiety and depression work temporarily and while in the body. In comparison, the benefit of psychedelic medicines comes from the insights gleaned during the few hours of a psychedelic experience (Waldman, 2019).
Serious consideration for psychedelic-assisted therapy is timely for Canadians facing end-of-life. There currently exists a well-documented need for mental health services in Canada with barriers including long wait times and a shortage of accessible mental health professionals (Moroz et al., 2020). Furthermore, the proposed 2023 changes to MAID criteria aim to include individuals whose only medical condition is mental illness. Indeed, current MAID eligibility includes unbearable physical or mental suffering from an illness that cannot be relieved under conditions the individual considers acceptable. Psychedelic-assisted therapy offers a potential new avenue to help relieve this mental suffering; the researched benefits to mental health, wellbeing, and quality of life complement current practices and therefore should be considered as an added option under the end-of-life umbrella.
A Call to Action
Over the past 6+ months, the Canadian Psychedelic Association has been meeting with Members of Parliament, senior government officials, representatives from all parties, and national stakeholders and has encountered unanimous support for access to psilocybin therapy with a palliative diagnosis. Furthermore, polling numbers show that 78% of Canadians would support a government that legalized psilocybin-assisted psychotherapy to improve the quality of life for terminally ill patients.
The Psychedelic Association came together with a group of experts including palliative care professionals, therapists, physicians, non-profit organizations, industry, medical, and legal experts to communicate, petition, and deliver an evidence-informed regulatory framework to officials at Health Canada. These regulations aim to transform the lives of Canadians by granting access to a new medicine that can help navigate profound mental distress. This is a call to support compassionate medical access to psilocybin-assisted therapy for end-of-life anxiety or for individuals with a palliative care diagnosis. Follow the Canadian Psychedelic Association for more updates. www.psychedelicassociation.net
