Small Changes Big Impact
Small Changes Big Impact
Challenges with MAID with Dr. Kimberly Wintemute
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In the studio today, we have Kimberly Wintemute, a family physician at North York General Hospital and assistant professor at the Department of Family and Community Medicine at the University of Toronto. She's also the primary care co-lead for Choosing Wisely Canada. Today's episode focuses on medical assistance in dying (MAID). We explore Dr. Wintemute's experiences and challenges with MAID, and the impact it's had on her life personally, and professionally.
Small Changes Big Impact a DFCM podcast. I'm your host, Dr. Jeremy Rezmovitz. In the studio today we have Kimberly Wintemute a family physician at North York General Hospital, assistant professor in the Department of Family Community Medicine at the University of Toronto. She's also the primary care lead for Choosing Wisely Canada. Today's episode focuses on medical assistance in dying. We explore Dr. Wintemute's, experiences and challenges with MAID and the impact it's had on her life personally and professionally. I hope you enjoy the show. So thank you for coming today. Um , to small changes big impact. I am so excited to hear your story. And , uh, tell us like, what , what grabbed you? Um, what did I do? What did I say that, that attracted you to come and sit here with us today?
Dr. WintemuteSo first of all, the whole concept of a podcast which was put out to the Department at large , uh, grabbed me. I thought it was timely. Modern , uh, could cover a variety of topics , uh, as physicians we seek to learn and better ourselves. And I thought that this was a great avenue to do that.
Dr. RezmovitzOkay. And , um, so what got you to say yes? What, what small change have you made that you thought, you know what, I have a story to tell.
Dr. WintemuteIt wasn't completely apparent to me at the beginning. In fact, when we as a committee started talking about this podcast thing, I thought, oh great, I'll talk about Choosing Wisely Canada, you know, like what a great opportunity to , uh, put out to the Department, you know, certain things about choosing wisely. And then as it evolved and , uh , it became Small Changes Big Impact , um, it became clear to me that there was a different change that I had made that was , uh, that had started off very small. And that has transformed into something really huge for me personally and, and I think is also , um, rippling through society in unexpected ways.
Dr. RezmovitzWow. Okay. I think you need to expand a little bit on this small change that you've made because , um, I , I think we want to know what, so what happened? Tell me.
Dr. Wintemuteso in the spring of 2016, I returned an email and in that return email I said yes. And that was the change. Um, it was an email from the VP medical at my site, which is North York General. And , uh, she sent an email out to the physicians on staff , um, and asked the question, when medical assistance in dying , uh, becomes legislation and is put into action, would you be willing to , uh , provide that service or be engaged somehow in providing that service? And I had been thinking about it, I had been following the discussion, obviously the social discussion , uh, through media. Um, and , uh, and I said yes.
Dr. RezmovitzOkay. So my question to you is, what was the change you said that you said yes, was the change. Do you not usually say yes?
Dr. WintemuteWell, I do say yes, but that was a , uh , particularly, you know, that that was something that had larger impact in the sense that, you know, it wasn't a question like, would you cover a shift for me or would you work in this Department or that Department? This was about taking on something new. Um, and it, you know, it hearkened back to, I was taking a PLI course, the Physician Leadership Institute at , uh , through CMA and , uh, the incredibly brilliant Canadian, Janice Stein was , uh, our teacher. And this was probably five or six years ago. And she said, she said, you know, watch this business about medical assistance in dying. This is a baby boomer issue. The boomers will not rest until they've got this. And remember she said, the boomers are used to having everything they want. Uh , they have been the largest group in society their entire lives. They have marched through life being the loudest voice and , uh , and they will get this one. Um, and that, that really, for some reason that really got my mind going. And , uh , so I followed it very carefully and , um, and by returning that email , um, it opened up a whole new world.
Dr. RezmovitzTell us, tell me what was the new world like, what was the process that happened with the small change? So you said yes to an email. So something came through your email box unexpected. Had you already done the PLI course to at least be aware of the fact that this is something that you may want to be involved in or did you go and say, Oh, this is something new? And then , um, the two kind of came together, like, tell us about the process, how this really.
Dr. WintemuteSo, the PLI course was probably five or six years ago, so it preceded the really active discussion that was going on , um, in the media and in government. Um, and uh, yeah, and then the email came a few months before the legislation was passed and , uh, and the you, before everything was kind of worked out provincially in terms of how this care would be delivered. Um, so , uh , can I pick it up after, after, after the email. Um, and you know, one of the things is that , uh, I am , uh, I have a fairly minimalist approach to life. I have, I, you know, I live very modestly. I don't seek, you know, grandeur. I don't seek material things. Um, and it comes that that ethic comes through to the care that I provide. Uh , in many ways. Um, it's certainly, it's certainly the principle that drew me toward working with choosing wisely Canada. Um, and it, and it speaks to me in my care of patients.
Dr. RezmovitzSo it's interesting. I totally prep for Choosing Wisely Canada. I invited you, I thought for sure we're going to talk about Choosing Wisely Canada, but I'm fascinated to know what your principles were, what your values were that maybe had you shy away from a medical assistance in dying and then what you've gone through now and maybe a patient story that's , um, had an impact because you said yes to, to that email.
Dr. WintemuteSo the, the , um, the concept of medical assistance in dying somehow spoke to me on that level. You know, more is not always better, you know, more, more time isn't always better. Um , more suffering isn't always better, you know, more, more time can be better if you're not suffering, if you're not , um, uh , distressed in , in ways that, that can't be overcome. So, so I think I was drawn to the concept, you know, on that level. And we, we know as family physicians, you know, older people feel better when they're on fewer medications. They, they fall less, they do better. Um, so we, we know that, you know, less is more very often. Um, so in the world of , um, medical assistance in dying, the way, the way that things played out after I said yes, was the , um, the VP medical , um, was one of the first people providing the service and , uh, emailed me or maybe phoned me and , uh, and said, this is months later after the legislation and said, I'm doing a MAID case. Would you come with me just to observe your first case? Uh, so that felt safe. That felt manageable. Um, so I did and it , um, you know, it was, it had some unexpected features for me. I imagined that people who were about to die might want something spiritual to happen. You know, maybe I'm just projecting my own, you know, wishes or, you know, thoughts for that kind of moment. Um, and , uh , and this person really did not , um, it was at home. The patient was in their bed. Um, and there was music playing. Um, this person had prepared all of their papers and they were on the desk and, you know, showed us where they all were. Um, they had no family. Um, and I said, I S I said to the patient, I said , uh, would you, you know, would you like me to , um, you know, to, to say anything to talk to you to , um, do, is there anything I can do that would be, that would provide comfort to you? Nope. It was really simple. There was nothing , you know, and, and , uh, so one of the things I've learned doing these cases is that people who have a spiritual sense have looked after that by the time this moment comes , um, and, and maybe some of them don't have spiritual needs, and that's okay too. Um, but , uh, but people who make this decision are very certain and very ready.
Dr. RezmovitzSo are the people that you're seeing right now, are they the front end of the baby boomers?
Dr. WintemuteWell, actually, another thing that surprised me about this was that most of the patients , uh , that I've looked after have been in their eighties and nineties. So they're not actually the boomers that's right there , the boomers, parents , um, or the boomers, aunties and uncles. Um, so it's, it, it, it was not who I expected it to be.
Dr. RezmovitzSo there's sound, it sounds like there's a lot of , um, unexpected , uh , learning that went on through this process for you. Um, what was the biggest barrier you think for yourself in learning this process?
Dr. Wintemute[inaudible] well, you know, in learning how to do it is, is easy for any physician, right? So we all know how to draw up medications. We all know how to, you know, test an IB , give IB medications, be with families. Um, but the, the primary barrier, the real challenge for me happened after the third case. I had an existential meltdown. I thought, what am I doing? Um, in what sense? So first of all, I think when I said yes, that I would do this work, I really thought the cases would be few and far between. This would not happen often. So I did one case and then maybe a couple of months passed before case number two was offered to me. But then case number three was very quick on the heels of number two. Um, and so that was a bit unsettling for me. I thought, Oh gosh, this is gonna happen all the time. Uh, it was another at home death. Um, the, the patient had a progressive neurological condition , um, and it wasn't, you know, the , um, that one's natural death can be reasonably foreseen , uh, that you know, that that's where the real judgment, when you provide eligibility assessments for MAID, that's where, you know, the real judgment comes clinically. And so if a patient is quite fun in , you know, in functional decline, that's really clear, let's say in their dying of cancer, we know that trajectory really well. But there are other disease processes where it's not, you know, where the timing of a natural death isn't a as obviously a parent . But what is certain is that the disease will cause one's death . So there was that aspect of it. And then the other aspect of it was, it was a Jewish family. And I, I thought, I don't know . We, we went, we, we went, there was a Moses on the door. And I thought, what , you know what I mean? Jewish people choose life. You know, this , this, this feels a bit wrong. You know, and I felt like I had these own judgments going on in my, in my own mind. I'm not Jewish, but, you know, I thought, Oh, hmm. So in we went and the family was gathered, the children , uh , the patient's spouse , um, they had spent the weekend at the family cottage , uh, which was exactly how this person wanted to spend their last days. And that day , um, that patient had , um, had eaten their favorite dessert, which was a cobbler made by their grandchild. Uh, and they were just, there were so many touching elements to, to the story. I, it really hit me in the, in the days that followed , um, and I found that I needed to, I needed to process it. And what had been happening was, I guess people were beginning to provide medical assistance in dying, but no one was talking about it. So it was a little bit like, we all know that there are doctors who perform abortions, but we might have a hard time naming any , uh, this was kind of being done in the background and without any chatter. Um, and I reached a point after that case where I needed to process and I didn't have a colleague that I had talked to about the fact that I was doing this or anyone in my family. Uh, so I went to speak to an Anglican priest and, you know, I said, you know, like I'm distressed, like I need to figure out what I'm doing and what this all means. And , uh, it was super helpful.
Dr. RezmovitzWhat was the most distressing part for you?
Dr. WintemuteUm ,
Dr. Rezmovitzso the conflict of values, principles that you were, went to medical school with anticipation or , um , an idea of what you were supposed to do as a physician.
Dr. WintemuteI'm not actually sure. I , I'm , I might still not be sure why that hit me so hard. There's, you know, I'm deeply spiritual and I , um, and I, and I, and I really, I respect , um, the spirituality that people have in their lives, even if that's, you know, apparently none. I think we all, we all do have that in our essence. But I think honestly, what was hard for me was that was that I saw a family making a choice that seemed so , uh, dissonant to me. Um, and, and that shook me up a little.
Dr. RezmovitzWhy the incongruency? What, what was I , I don't understand cause this is your third case.
Dr. Wintemute[inaudible] [inaudible] um, well after case number two, I was in a nursing station in one of my internist colleagues , uh, who had been the MRP for the patient. He took me on right in the nursing station. He said, he took me on, he said to me , uh , you know, we had just completed the case and he said , uh, Kimberley, how do you feel after do something like that? And that really took me off guard, right? Because, because actually when, when you're going through the mechanics of a case , um, well for me anyway , um, there is a little bit of detachment that that needs to occur to, to move, to move through that. And I think he caught me at a moment where I was experiencing that detachment. I was still in that , um, and I felt a bit ticked. I thought, O h, how could he take me on right in the nursing station about that. And I fumbled through the conversation, not, you know, not entirely sure how to respond, but, but that also gave me pause and I thought a lot about that in the ensuing days. And I bumped into that same colleague probably the following week in the doctor's lounge, you know, at which time I was able to say thank you for taking me on. Thank you for shaking me up a little bit. And um , moving me to, you know, maybe deeper reflection.
Dr. RezmovitzWas it deliberate? Did he really take you on?
Dr. WintemuteHe did.
Dr. RezmovitzSo it was, it was deliberate confrontation.
Dr. WintemuteIt was a bit confrontational. He's not a confrontational colleague, but he was confronting me on an intellectual basis.
Dr. RezmovitzI wonder if the challenge for him was neutral, but for you, because of this area and how you felt about it was, was felt that it was confrontational.
Dr. WintemuteMaybe he, he, but I don't think he's neutral and we've had subsequent discussions about it. It turns out that we, we actually both identify with the same church, the Anglican church. So that actually permitted a way of having conversations about this and, and somehow I think allowed him to , uh, view me, you know, not as some kind of thoughtless , um, you know, robot doing this work, but, but, but as someone who was, who was thinking about it and considering it deeply, so I was a bit shaken. And so that was a second case. I was a little bit shaken. And then by the time I got to the third case, this, this other piece hit me , um, and this piece about , uh, about another religion and it , it , it made it hard for me. Um, so.
Dr. RezmovitzWhy?
Dr. WintemuteI don't know if I can answer that. Okay . After the case , um, at that patient's funeral, the family spoke openly about the fact that they had died , uh, with medical assistance and they sent the video of the funeral , um, to us and, and I watched it. And I cannot tell you how , uh, comforting that was to me. Um, and , uh, not to make it all about me, but that, that, that, that whole funeral actually helped me heal from that, from that episode. Um,
Dr. Rezmovitzokay .
Dr. WintemuteAnd, and I want to tell you about something else that happened recently and I've probably done, I don't know , maybe 15 , uh , cases now and more recently, and this is Epic. Jeremy, a Catholic family. Um , the spouse of the person who was dying was quite distraught that the patient had requested, MAID, went to speak to the priest at their parish. And remember that MAID is verboten in, in Catholicism. And , and in fact , um, it was either just before or just after the legislation was passed. The , um, the Catholic diocese of Toronto put out a statement on MAID. Um, and I knew it was coming cause it was in the news. And , uh, I went to a Catholic church that Sunday. I thought, I've got to hear this. I've got to hear what, what's gonna be put out in every Catholic parish in Toronto this Sunday. And there were, I think it was 14 points that were made, three of which were actually factually incorrect, which made me quite , um, you know, a little bit sad. Um, you know, but, but, but the rest of which, you know, they were, you know, they were discussion points about Catholicism and, and the deep meaning of the religion and the background, you know, and, you know, they , they made sense in, in that context. So this most recent case , uh, where the spouse of the dying person went to the priest at their parish , um, the, the priest told the spouse, the most important thing you can do right now is uphold the wishes of your spouse. They are suffering and we cannot understand their suffering. So write what you, what you need to do is support your spouse.
Dr. RezmovitzIt's a very patient centered approach.
Dr. WintemuteI was blown away. And, and, and that to me demonstrated that , um , medical assistance in dying is rippling through our society in unexpected ways. It's not obviously going away , uh, but, but perhaps many people are having unexpected responses to this. Um, yeah.
Dr. RezmovitzWhen you say unexpected responses, do you mean like the impact of the, let's call it a movement for lack of a better term right now, or a , an awareness that, A, this is available. B , it's permissible, it sounds like now. And so what are the unexpected , um, impact? What are the unexpected , unexpected impacts that you think that , uh, medical assistance in dying is having now going forward?
Dr. WintemuteI think that in some cases it is allowing compassionate understanding , um, to rise to the surface as the most important thing to uphold above religious doctrine, for example. And, and the other, the other thing that, that I've seen upheld is, is the sanctity of marriage. I was, I was deeply moved , um, in, in, in, in both of these cases, you know, that I've talked about that , uh, the, the spouses, you know, this is clearly a terribly painful thing for families. Um, and in , and in each of these cases, you're the person who was dying and their suppose had had a lifelong marriage , um, you know, decades upon decades. And , um, and I thought, wow, you know, the, the, these people that the spouses are really upholding the, the wishes of their spouses , um, and demonstrating a huge amount of compassion , um,
Dr. RezmovitzSounds like a huge amount of humanism, just being present and being able to care and demonstrate that empathy for their other, for their spouse is , um, it's, it's lovely to, to, to bear witness that. It sounds like it had a major impact on you and , um, it sounds like it's something that you're going to continue it sounds like. Yes. And it sounds like it has a major impact in our society going forward. Do you have any , um, advice for our listeners? Um, be they providers, be they patients as we're all patients. Um, so advice , um, maybe resources that you would recommend if people want to learn more. Um, and any parting words that you have?
Dr. Wintemute[inaudible] well, when I think back to when I first started doing this work and I wasn't talking to anybody about it, I realize now how hard that was. And , um, so I would encourage people if they are doing this work , uh, whether it's actually doing the procedures or doing eligibility assessments , uh, to connect with other people at their site or other people within our Department who are involved. Uh, because as time has gone on and , uh, I've been able to mentor two colleagues , um, who now who now do this , uh, two residents, a nurse practitioner. And that has actually given me the ability to have discussions and to debrief , um, about this kind of work. And that's , uh , that's important. Some , you know, it's important even after a long day at the office, you know, that we have , uh, that we're able to debrief. It's what we do. It's what we do after we're on call, you know, for example, the next morning we grab one of our colleagues and we talk about what happened during the night. Um, so , uh, yeah, so I would say , uh, don't feel , uh, we don't need to feel isolated doing this. We can support each other and I think it's really important.
Dr. RezmovitzThank you. Um, and with that, I think we're going to take a break. Um, it was a really nice, prayerful conversation that I think we had today. Um, I feel , uh, that we connected on a level today that , uh, I hope our listeners will connect, connect with as well. And so with that, I want to thank you , uh, the DFCM. Thanks you and , uh, wish you a fond , uh, do take care. Thanks, Jeremy. This podcast was made possible through the support of the Department of Family and Community Medicine at the University of Toronto. Special thanks to Allison Mullin, Brian Da Silva and the whole podcast committee. Thanks for tuning in. See you next time.