After practicing medicine for more than two decades, Victorian physician Dr. Stefanie Green decided to focus on the practice of physician-assisted dying. In his memoirs, It’s assisted dying, she shares her deeply personal and professional encounters with patients, their families and the practice as a whole. Green believes it’s important for people to continue conversations about assisted dying, whether you agree or not. From the emotional process involved in physician-assisted dying and the challenges that come with it, to the role families play in that journey, the book, which was released on March 29 this year, covers it all.
Portions of this interview have been edited for length and/or clarity.
VM: Tell us about your book, It’s assisted dying.
Dr Stefanie Green: There are so many things that I don’t know where to start. My book is a medical memoir about my first year of medical assistance in dying here on Vancouver Island in Canada. It’s based on 2016, the year the law changed, and it’s about what assisted dying is and how it works. It’s about what it feels like for the people involved and what it feels like for me to get the job done. There is also a very personal thread that weaves itself throughout the story. I think some people may think it’s a textbook. It is not: it is a story, and I think it is accessible to a large number of readers.
VM: Where did you get the inspiration to write your memoirs?
OS: When I first started practicing physician-assisted dying, it was brand new care, something I had never been asked to do. Something no one in Canada had been asked before. And I had already been practicing medicine for 25 years, so that was really a whole new chapter. There were many, many challenges and obstacles, but I kept finding myself in these extraordinary circumstances with patients asking me to do things that I had never been asked to do before. Patients were expressing their gratitude and relief, I was so amazed at some of the things I had seen and felt that I started taking notes to myself. At that point I was approached and asked to consider writing a book and decided to take the plunge.
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VM: What is your first memory of medical assistance in dying for a patient?
OS: The very first time I provided medical assistance in dying to a patient is a story I tell in my book, it was for a gentleman I call Harvey and it is etched in my memory forever. It was the early days when it was legal, and it was an amazing family facing the unknown. They were supportive of their loved one and put their wishes and needs above their own.
I feel very lucky to have been involved with them from the start. I think they showed me how it could happen and how it could go without much guidance from me. It was a natural support that they gave to their loved one and it was a very, very privileged position for me, I felt, to be involved in that inner circle and to provide that care.
VM: Did you find frightened patients sometimes? Or a time when a patient was unsure of their decision?
OS: I have never helped anyone who had doubts about whether it was the right decision for them. Because it is important in our process — and within the law — that we give them the opportunity to change their mind until the very last moment. And unless I’m convinced it’s true, I won’t go ahead.
I think it’s fair to suggest that people are sometimes scared. I get a lot of people asking me, you know, what do I think is coming next? What’s on the other side? And I think that may scare some people and not scare others. I think people struggle with that. My very first patient Harvey told me explicitly that he was a little scared. Not because of his decision, he was very determined to move forward, but he just didn’t know what was in store for him next. We had a very raw and very, I would say, intimate conversation about what he thought could come next, what I thought could come next, and why it was important or not important. And I think it’s just important to explore what people are feeling, to give them the space to do that.
VM: How would you answer the question about what comes next?
SG: Well, I honestly answer that I don’t know. I really don’t have the answers and I’m used to thinking and asking people what they think is coming next. I heard a somewhat flippant answer recently, which I love, and may need to use. It’s not my quote, but they said, “Well, if nothing exists, the dead don’t care. But if anything else exists, boy, what an adventure it’s gonna be. And I thought, well, that’s an interesting way to look at it. So the answer is, I don’t know, but I’m hoping someone will flag me down and give me a hint.
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VM: Is there another patient in your book who has really marked you as a writer?
SG: It was difficult to know what stories to tell and not to tell. There are so many who follow me. One of the spouses had a hard time saying goodbye at the end – the experience I had with her about checking to make sure her husband was dead was very emotional and will probably always stay with me.
I think the story I end the book with is probably the one I would go to next, which is Richard’s story. The scene his wife created very naturally when he died in their bed together literally looked like a scene from a movie. It was an incredibly moving moment, and I will never forget the feeling of being in that room.
VM: What are some of the challenges of broaching a topic that can be so emotional and sensitive?
SG: That’s a great question. The first thing is to understand and recognize that this can be an emotional and sensitive subject. That’s one of the reasons why I think it’s important that I write this book. I see medical assistance in dying as the courts and the government of this country see it: it is a legal, available and covered medical service. And I think as such, it needs to be talked about. It needs to be explored and understood, and even debated. It must be out in the open. The last thing that should happen is that it happens behind closed doors.
One of the reasons I wrote this book is to contribute to the conversation about death and dying, and end-of-life care options in general. Whether or not you believe in physician-assisted dying, I think these are conversations Canadians need to have, and I hope my book will facilitate those conversations. For me, that would be a success.
VM: What does this open conversation look like to you?
SG: I do this with sensitivity, with honesty, with direct information, without inflammatory language, out of respect for those who might have a different opinion, and with curiosity about what others think and why. I think these are the main things you need to keep in mind when discussing this topic.
VM: How does the assisted death process work? What does it look like?
SG: If someone in Canada wants assisted dying, they must apply for it themselves. They must make a formal request in writing which must be signed, dated and attested. And once that happens, it triggers the next process. They must be assessed by a clinician, either a physician or physician or nurse practitioner, to see if they meet the eligibility criteria, which are rigorous and robust. Two different clinicians must independently agree that they meet these conditions.
And if they do, then they have the possibility of having witnessed the death. Once the eligibility criteria have been met, there are several procedural safeguards. Things like having that application form in writing and dated, things like giving consent. There is a whole list of other guarantees that must be respected. If both independent doctors agree that you meet all the conditions, then it’s up to the patient to decide, but that still doesn’t mean it’s going to happen. It means that box happen if the patient feels really necessary. And then it’s just a matter of logistics regarding the organization and choreography of the final event. Planning it, making sure all the factors and parts are in place, the medications, the nursing support, things like that. It’s the process.
VM: Is there anything else you would like to add?
SG: The only thing I would like to point out is that I am the co-founder and president of a national organization that supports the people who do this work, the Canadian Association of MAID Assessors and Providers (CAMAP). And I think it’s important for people to know that the clinicians and the teams of professionals who support them take this work very seriously. It’s not something that people enter lightly. It’s not something people do without a lot of thought and consideration. The clinicians who do this work do it with professionalism, responsibility and rigour.