> Zed Book Club / Dr. Jean Marmoreo Explores the Importance of Medically Assisted Death From the Patient’s Perspective in ‘The Last Doctor’

Dr. Jean Marmoreo says each of the seven patients featured in her book taught her a lesson about Medically Assisted Death in the early days of its legalization. Photo: Courtesy of Bob Ramsay

> Bookshelf

Dr. Jean Marmoreo Explores the Importance of Medically Assisted Death From the Patient’s Perspective in ‘The Last Doctor’

In a Q&A, Dr. Jean Marmoreo talks about the patient who inspired her to write about medically assisted death and the importance of debunking common misconceptions about the practice. / BY Kim Hughes / October 14th, 2022


Doctors helping terminally ill patients die has been legal in Canada for less than a decade. But the demand for what’s known officially as medical assistance in dying (MAID) is steadily growing. In lockstep have come memoirs from those doing the work, giving a potentially fraught subject a human face and thoughtful backstory.

In The Last Doctor: Lessons in Living from the Front Lines of Medical Assistance in Dying, out now, long-time Toronto-based family physician and MAID provider Dr. Jean Marmoreo makes it clear that those electing to end their lives with a clinician’s help are empowered and experiencing a death of “autonomy and dignity” rather than suffering an intractable slide into pain, disability, and dependence. 

Co-written by Marmoreo with journalist and longtime Zoomer contributor Johanna Schneller, The Last Doctor is the second book about medically assisted dying in Canada to hit shelves this year, after Dr. Stefanie Green’s This Is Assisted Dying: A Doctor’s Story of Empowering Patients at the End of Life. 

As they tell it, both Green and Marmoreo were committed to offering the procedure from the beginning — technically February 6, 2015 — when the Supreme Court of Canada ruled in a landmark case that prohibiting a very sick individual from requesting an assisted death was contrary to the Charter of Rights. 

The law kicked in a year later and has since been updated to include “those whose natural death isn’t yet reasonably foreseeable,” allowing, for example, younger people facing lifelong degenerative diseases access to MAID, as well as permitting a “waiver of final consent” for those on track to suffer grievous cognitive impairment, such as Alzheimer’s.

Since then, according to the Third Federal Annual Report on Medical Assistance in Dying recently issued by Health Canada, some 31,664 individuals have died this way, at an average age of 76.3. The report adds that in 2021 alone, there were 10,064 MAID deaths — officially referred to as “provisions” — accounting for 3.3 per cent of all deaths nationwide. That number represents a growth rate of 32.4 per cent over 2020 with all provinces experiencing year-over-year growth, according to the report.

These numbers are no surprise to Marmoreo who, like Green — the latter the co-founder and current president of the Canadian Association of MAID Assessors and Providers (CAMAP), of which Marmoreo is a member — sees agency over one’s death as a fundamental aspect of quality of life. As Marmoreo writes, her obligation to provide provisions to those meeting eligibility criteria for MAID is obvious.

“My ideal was cradle-to-grave care: to begin with a patient in young adulthood and stay with them until the end. My younger patients often said, ‘You cannot retire before I die!’ and my response was always, ‘I’ll be dead before you, never fear.’

“But there were many patients for whom I could not provide the end-of-life care they sought. The gravely ill and those facing dementia didn’t want me to prolong their lives. They wanted me to ease them out. They didn’t want to linger in terrible pain, dependent on others for their most basic personal care. They didn’t want to deteriorate until they no longer recognized their own children.”

In her book, Marmoreo — 80 last August, and whose website accurately describes her as “doctor, writer, athlete, advocate, adventurer” — tells the story of seven actual patients with varying illnesses whose lives she helped to end with their consent and gratitude, as loved ones looked on. She spoke with Zoomer about the book, and what, if anything, the fallout from COVID-19 has brought to the discussion about end-of-life care.

 

Kim Hughes: Had you always intended to write a book about your MAID work?

Jean Marmoreo: Never was it in my mind. But even though I hadn’t planned to write a book, as a clinician I already had very detailed notes. My patient Yolanda (described as “only forty-five, but sick with a rare lung disease for thirty years”), who is threaded through the book, had a vital story of her own and could help people understand what MAID should be and what it entailed. She was kind of the driver of the book. I put (co-author) Johanna onto Yolanda because I also wanted to tell this story but because I was her physician, issues of confidentiality prevented me from telling it. So, Johanna made Yolanda’s story public. That was the genesis of the book.

KH: So, the patients presented in this book are real people, not composites?

JM: There are no composites except for the very end, the last two chapters, I used pseudonyms. But when we sat down to select the patients and came up with these seven stories, it was because each of those patients had lessons for me. And that was because most of these provisions happened in the early days of MAID when we were scrambling to figure out how to do this in a consistent, reasonable manner. And not just me but all the providers across Canada who were working out how the legislation should best be applied. Even though it was a federal decision, each province directs its own health care service. Every province has a slightly different iteration of how the legislation is applied. We wanted to ensure that all standards were very high.

KH: In her book, Dr. Stefanie Green argues that the subject of death should be normalized, that people should discuss their wishes about their own death with family while they still can. Is that your goal too?

JM: Absolutely. These are conversations we should be having with extended family around the Christmas dining room table. Families rarely come together in times of joy, mostly at funerals when nobody wants to talk about this stuff. If you believe that life is a celebration, you should honour that by knowing it won’t go on forever. The ending should reflect the richness and goodness of life. 

KH: Where does Canada sit in the hierarchy of countries offering medical assistance in dying? Are we at the top, or in the middle?

JM: The template we used in Canada was what the Benelux countries (Belgium, Netherlands, Luxembourg) had done. Their model came into effect around 2012 and we have sort of followed them along. A key difference is that, if you’re in Holland, 75 percent of provisions are done by family doctors working with their own patients. That was certainly the model I initially had in my head although that hasn’t been the case here. Instead, there are a select group of physicians and nurse practitioners across Canada — some 1,500 now I think — who are doing medical assistance in dying. 

We are increasing at 30 percent per year; last year we were at about 30,000 (medically assisted deaths). From that perspective, there are not enough doctors across the country doing this work. My expectation is that we are heading towards four to five percent of deaths annually being assisted deaths.  It does vary from province to province but a high percentage of people with cancer request assisted deaths because they know what’s coming and they don’t want to go there. They want autonomy and dignity. 

KH: The pandemic exposed the woeful state of our country’s elder care. In that context, a very moving passage in your book says, ‘If the only reason I’m providing MAID is that it’s easier to die than it is to get decent, deserved help, then I risk being merely an expedient solution. I simply won’t be that.’ Will this book have an impact on how we care for our elders?

JM: Oh man, I hope so. The pandemic exposed terrible flaws in long-term care that we have been ignoring for 25 years. I mean, we saw it: those dying in the greatest numbers in the early days of COVID were those in long-term care. When you have to call in the military to clean up the mess, it’s a national shame. People at the end of their lives need the most hands-on care but they often cannot advocate for themselves, and don’t have the cognitive abilities to speak for themselves. And it hasn’t changed one bit [since the pandemic].

KH: Permit me to say, you’re an astonishingly vibrant 80.

JM: Yes, though I am definitely at the tail end of my life. Which makes me worry. Who is coming up behind us to do this work as we providers age? Who is going to step in and carry on when we are gone? We are finite beings as well. This work must be taken up by younger people.

KH: What’s the most important thing for people to know about your book?

JM: I had a conversation with a woman in Newfoundland recently who didn’t know this [kind of care] was available. I don’t fault her for not knowing but I do feel that we need to start at the beginning. We have only been doing this for six years. People must understand this is not a dial-a-death operation. People must meet extensive eligibility criteria, and it’s not easy to access an assisted death, although I can tell you candidly that we can turn it around in 24 hours if we have to. 

That said, you have to open the conversation with people who are failing, to ask, ‘What gives you joy and comfort? What is tolerable?’ It’s amazing how much people are willing to endure rather than stopping to ask, ‘Is this what I want for myself?’ Health care is so driven to the next option of care, and people just take it. Then suddenly they have no quality of life. They are suffering through the cure rather than evaluating their quality of life. There are other options. 

Those interested in this subject might also wish to explore the documentary Last Flight Home, which chronicles an America man’s journey through the end of life.

THE SCROLL

Here are the 5 Books on Bill Gates’ Holiday Reading ListThe billionaire philanthropist is giving hundreds of copies to little libraries around the world


Sheila Heti and Eli Baxter Among 2022 Governor General’s Literary Award WinnersToronto writer Sheila Heti took home the fiction award for 'Pure Colour,' a novel the GG peer assessment committee called "a work of genius."


Suzette Mayr Wins $100,000 Scotiabank Giller Prize for ‘The Sleeping Car Porter’The 2022 Giller Prize jury called Mayr's novel "alive and immediate — and eerily contemporary."


Writers’ Trust of Canada Awards: Authors Nicholas Herring, Dan Werb Nab Top PrizesThe Writers' Trust of Canada awards amounted to a combined monetary prize value of $270,000.


Bob Dylan Releases ‘The Philosophy of Modern Song,’ a Book of Essays Dissecting 66 Influential SongsIn his new book, Bob Dylan offers up both critique and historical insight into various musical recordings of the last century by a variety of popular artists.


Prince Harry’s Memoir ‘Spare’ Will Be Published in January 2023The long-awaited memoir will tell with "raw unflinching honesty" Prince Harry's journey from "trauma to healing", his publisher said on Thursday.


Sri Lankan Author Shehan Karunatilaka Wins 2022 Booker PrizeKarunatilaka won the prestigious prize on Monday for his second novel ‘The Seven Moons of Maali Almeida’, about a dead war photographer on a mission in the afterlife.


Canadian Council for the Arts Reveals Governor General’s Literary Awards FinalistsThe finalists for the Governor General's Literary Awards spotlight books in both the English and French language, as well as translated works.


New Penguin Random House Award Named After Michelle Obama Will Honour High School WritersMichelle Obama Award for Memoir will provide a $10,000 college scholarship to a graduating public school senior based on their autobiographical submission.


French Author Annie Ernaux, 82, Becomes First French Woman to Win Nobel Prize for LiteratureThe author said, of winning, that "I was very surprised ... I never thought it would be on my landscape as a writer."


Hilary Mantel, Award-Winning British Author of ‘Wolf Hall’ Trilogy, Dies at 70Wolf Hall, published in 2009, and its sequel Bring Up the Bodies, released three years later, both won the Booker Prize, an unprecedented win for two books in the same trilogy and making Mantel the first woman to win the award twice.


Prince William “Cannot Forgive” Prince Harry, According to ‘The New Royals’ Author Katie NichollPrince William “just cannot forgive his brother,” according to Katie Nicholl, author of 'The New Royals: Queen Elizabeth’s Legacy and the Future of the Crown.'


Five Finalists Announced for Hilary Weston Writers’ Trust Prize for NonfictionThe winner — to be announced on November 2 — will take home the annual $60,000 prize.


Peter Straub, Bestselling American Horror Writer, Dies at 79Friend and co-author Stephen King has said the author's 1979 book, "Ghost Story," is his favourite horror novel.


Rawi Hage, Billy-Ray Belcourt and Sheila Heti Make the 2022 Scotiabank Giller Prize Long ListThe jury read 138 books to choose 14 titles for the long list, one of which will win the $100,000 prize, one of the richest in Canadian literature


Salman Rushdie, Novelist Who Drew Death Threats, Is Stabbed at New York LectureThe Indian-born novelist who was ordered killed by Iran in 1989 because of his writing, was attacked before giving a talk on artistic freedom.


Raymond Briggs, Creator of Beloved Children’s Tale ‘The Snowman’, Dies at 88First published in 1978, the pencil crayon-illustrated wordless picture book sold more than 5.5 million copies around the world while a television adaption became a Christmas favourite in Britain and was nominated for an Oscar.


Canadian Author Emily St. John Mandel Makes Barack Obama’s 2022 Summer Reading ListObama's list includes everything from fiction to books on politics, cultural exploration and basketball.


Canadian Author Rebecca Eckler to Launch RE:books Publishing House Focused on Female Authors and Fun ReadsThe former National Post columnist says her tagline is ‘What’s read is good, and what’s good is read.’”


Brian Thomas Isaac’s “All the Quiet Places” wins $5,000 Indigenous Voices AwardThe B.C. author, a retired bricklayer, drew on his childhood growing up on the Okanagan Indian reserve for his coming-of-age story set in 1956


Canadian-American Author Ruth Ozeki Wins Women’s Book Prize for “The Book of Form and Emptiness”The UK judges said her fourth novel, inspired in part by the Vancouver Public Library, contained "sparkling writing, warmth, intelligence, humour and poignancy."


The Bill Gates Summer Reading List Includes a Sci-Fi Novel On Gender Inequality Suggested by His DaughterBill Gates' summer reading list includes fiction and non-fiction titles that cover gender equality, political polarization and climate change.


American novelist Joshua Cohen wins the Pulitzer Prize for fiction for “The Netanyahus”The 2022 Pulitzer prizes include this satirical look at identity politics, focused on the father of former Israeli Prime Minister Benjamin Netanyahu, at a crucial time in the Jewish state’s history


Margaret Atwood, Alice Munro Among Canadian Authors Recognized in Commemorative Reading List Marking Queen’s Platinum JubileeThe authors are among six Canadian scribes included on the The Big Jubilee Read list.


Queen Elizabeth II’s Aide Reveals Details of Life in Royal Pandemic Lockdown in New Addition to BookAngela Kelly, who's worked for the Queen for 20 years, discusses everything from cutting the Queen's hair to "the light and laughter that was shared ... even in the darkest moments."


New Leonard Cohen Story Collection, ‘A Ballet of Lepers,’ Set for October ReleaseThe collection features a novel, short stories and a radio play written between 1956 and 1961.


Archived Letters Reveal How Toni Morrison Helped MacKenzie Scott Meet Future Husband Jeff BezosBezos hired Scott at the hedge fund where he worked after receiving a recommendation from Morrison. Shortly thereafter, the pair married and Scott helped Bezos launch Amazon.


Prince Harry’s Memoir is Set to Rock the MonarchyFriends say the California-based royal got a million-pound book deal to write "an intimate take on his feeling about the family."


European Jewish Congress Asks Publisher to Pull Anne Frank BookThe Congress says 'The Betrayal of Anne Frank' has "deeply hurt the memory of Anne Frank, as well as the dignity of the survivors and the victims of the Holocaust."


Canadian Author Details Anne Frank Cold-Case Investigation That Named Surprise Suspect in Her Family’s Betrayal in New BookAhead of the 75th anniversary of the publication of Frank's 'The Diary of a Young Girl' in June, a team that included a retired FBI agent and around 20 historians, criminologists and data specialists identified a relatively unknown figure as a leading suspect in revealing her family's hideout.


Man Who Tricked Authors Into Handing Over Unpublished Manuscripts Arrested by FBI in New YorkFilippo Bernardini, an employee of a well known publication house, has been arrested for stealing hundreds of unpublished manuscripts.


Hollywood Legend Betty White Has a Last Laugh in New Biographic Comic BookThe creators of the biographical comic book have released similar books about Hollywood legends like Carrie Fisher, Lucille Ball, David Bowie and Elizabeth Taylor.


Barack Obama Reveals His List of Books That Left “A Lasting Impression” in 2021Obama's favourite 2021 reads include two-time Pulitzer Prize-winning author Colson Whitehead's 'Harlem Shuffle' and 'Klara and the Sun,' by Nobel Prize-winning author Kazuo Ishiguro


“Interview With the Vampire” Author Anne Rice Dies at 80 — Tributes Pour in From Stuart Townsend and OthersThe author, who was best known for her work in gothic fiction, died on Saturday evening as a result of complications from a stroke.


Norma Dunning wins $25,000 Governor General’s English fiction prize for ‘Tainna’The Edmonton-based Inuk writer explores themes of displacement, loneliness and spirituality in six short stories


Omar El Akkad wins $100,000 Giller prize for “What Strange Paradise”The former Globe and Mail reporter, who published "American War" to acclaim in 2017, tackles the global migrant refugee crisis in his second novel


South African Author Damon Galgut Wins the Booker Prize For ‘The Promise’Galgut received nominations for his 2003 and 2010 works before finally taking home the prize this year. 


Hollywood Legend Paul Newman Discusses Life, Acting and Aging Gracefully in Newly Discovered MemoirPublishers of the newly discovered memoir say the Hollywood legend wrote the book in the 1980s in response to the relentless media attention he received during that time.


Here’s What You Need to Know About the Toronto International Festival of AuthorsDirector Roland Gulliver lands in Toronto to open his second, much-expanded virtual festival with more than 200 events


Tanzanian Novelist Gurnah Wins 2021 Nobel Prize in Literature for Depicting the Impact of Colonialism and Refugee StoriesGurnah, 72, is only the second writer from sub-Saharan Africa to win one of the world's most prestigious literary awards


Miriam Toews Garners Third Giller Prize Nomination for “Fight Night” after Shortlist AnnouncedSophomore efforts from novelists Omar El Akkad and Jordan Tannahill join debut books from Cheluchi Onyemelukwe-Onuobia and Angélique Lalonde


Tina Brown’s New Book, ‘The Palace Papers’, Covers the Royal Family’s Reinvention After Diana’s Tragic DeathTina Brown's sequel to her 2007 release 'The Diana Chronicles' is set to hit shelves April 12, 2022. 


Audible.ca Releases Andrew Pyper’s Exclusive Audiobook “Oracle” For New Plus Catalogue LaunchThe thriller about a psychic FBI detective is one of 12,000 titles now available for free to members


Barack Obama and Bruce Springsteen to Release Book Based On Their “Renegades” PodcastThe new book will feature a collection of candid, intimate and entertaining conversations


Prince Harry Will Publish a Memoir in Late 2022Harry says he's writing the book "not as the prince I was born but as the man I have become."


> STAY UP TO DATE

Sign Up for the Weekly Book Club Newsletter