Learning from others
Assisted death has been legally available for years in other jurisdictions, such as Switzerland, the Netherlands, Belgium and some states including Oregon, Washington, Montana, New Mexico and Vermont. In some of these places, only assisted suicide is legal, which means that the patient must be able to take the medication himself or herself. In Canada, we will have both assisted suicide and euthanasia or assisted death available, so that the physician may write a prescription for medication that the person can take later at home or give the medication intravenously. In Canada, we believe that the rules we will be following will be similar to what other jurisdictions have required, including having two physicians sign declarations that the patient qualifies and is able to consent.  Each jurisdiction has slightly different rules, but one survey found high levels of adherence to these requirements in the four countries studied. 
A 2013 report from the Netherlands stated that the most common diagnoses in assisted deaths were cancer (74.3%); neurological disorders (6.1%); multiple geriatric syndromes (5.2%); and cardiovascular disease alone (4.6%).  In Oregon, the majority of patients receiving a physician assisted death had cancer, 68.6% in 2014 and an average of 79.4% between 1997 and 2013.  Not everyone who requests an assisted death actually has one; only 171/265 (65%) of lethal prescriptions written in the first 6 years in Oregon resulted in patient death. In 2014 in Oregon, most (89.5%) patients died at home, and most (93.0%) were enrolled in hospice care either at the time the DWDA prescription was written or at the time of death. In 2014, as in previous years, the three most frequently mentioned end-of-life concerns were: loss of autonomy (91.4%), decreasing ability to participate in activities that made life enjoyable (86.7%), and loss of dignity (71.4%).
There have been important qualitative (interview) studies done in the Netherlands with patients who requested physician assisted death (PAD) (whether they died by PAD or another cause or were refused PAD), their physicians and their most involved relatives [5-7]. In these studies, communication with the physicians was very important to the patients and was facilitated when physicians showed empathy, were clear about boundaries and helped patients organize their thoughts and express their feelings. Patients experienced barriers when they felt patronized and could not express their preferences. Decision making was easier when relatives were supportive. All the satisfied participants mentioned shared decision making, support of relatives and good communication. The same studies found that there were five main themes or stages of PAD: 1) initiation of sharing views and values about PAD, 2) building relationships as part of negotiation, 3) fulfilling legal requirements, 4) detailed preparations, 5) aftercare and closing. In another study of physicians in the Netherlands, they stated that they found the requests for assisted death stressful and that there was a careful balance between providing good palliative care and a peaceful death. . In a study of relatives of patients who had died by assisted death, 92% said that assisted death had contributed favorably to the quality of the end of life. . In a study of predictors of PAD in terminally ill patients in Oregon, low spirituality was the strongest predictor with other predictors being hopelessness, depression and dismissive attachment. 
Landry JT, Foreman T, Kekewich M. Ethical considerations in the regulation of euthanasia and physician-assisted death in Canada. Health Policy. 2015 Oct 22.
- Lewis P, Black I. Adherence to the request criterion in jurisdictions where assisted dying is lawful? A review of the criteria and evidence in the Netherlands, Belgium, Oregon, and Switzerland. J Law Med Ethics. 2013 Winter;41(4):885,98, Table of Contents.
- Regional Euthanasia Review Committee. Annual report 2013; 2014. Online resource. Available from ∗https://www. euthanasiecommissie.nl/Images/Annual%20report%202013 tcm52- 41743.pdf) (accessed: 21st August, 2015).
- Oregon Public Health. Oregon’s Death with Dignity Act 2014. Online resource. Available from ∗http://public. health.oregon.gov/ProviderPartnerResources/EvaluationResearch/ DeathwithDignityAct/Documents/year17.pdf) (accessed: Novermber 27, 2015)
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- Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Elwyn G, Vissers KC, van Weel C. Perspectives of decision-making in requests for euthanasia: a qualitative research among patients, relatives and treating physicians in the Netherlands. Palliat Med. 2013 Jan;27(1):27-37.
- Dees MK, Vernooij-Dassen MJ, Dekkers WJ, Vissers KC, van Weel C. ‘Unbearable suffering’: a qualitative study on the perspectives of patients who request assistance in dying. J Med Ethics. 2011 Dec;37(12):727-34.
- Georges JJ, The AM, Onwuteaka-Philipsen BD, van der Wal G. Dealing with requests for euthanasia: a qualitative study investigating the experience of general practitioners. J Med Ethics. 2008 Mar;34(3):150-5.
- Georges JJ, Onwuteaka-Philipsen BD, Muller MT, Van Der Wal G, Van Der Heide A, Van Der Maas PJ. Relatives’ perspective on the terminally ill patients who died after euthanasia or physician-assisted suicide: a retrospective cross-sectional interview study in the Netherlands. Death Stud. 2007 Jan-Feb;31(1):1-15.
- Smith KA, Harvath TA, Goy ER, Ganzini L. Predictors of pursuit of physician-assisted death. J Pain Symptom Manage. 2015 Mar;49(3):555-61.