Monday, September 18, 2023: CBC National news highlights the story of Saskatoon couple, Ralph Johnstone and Laura Bach, who simultaneously utilized medical assistance in dying, or MAID, to complete their life journey together. The family recalled the final week as one of “many wonderful conversations with a lot of their loved ones . . . it was like a living funeral” (Zakreski, 2023, para. 23). Such a story stirs emotions while at the same time disrupts beliefs and philosophies of life and ethics around MAID. Regardless of one’s views on MAID, the heart is tugged by such circumstances and stories and it appears that such tugs will only be rising on the horizon.
A Tidal Wave of Need
Across Canada, death rates are increasing with the gathering speed of the age-wave (Dychtwald & Terveer, 2023). This reality, coupled with unexpected deaths and health-related issues, is generating a tidal wave of demand upon the health care system. According to the BC Centre for Disease Control, COVID-19 was a pandemic that generated an extreme number of unexpected deaths, with 3,002 occurring during the month of September 2022 alone (Provincial Health Services Authority, 2022). In the summer of 2021, due to a heat dome in the province of British Columbia, 619 individuals died (BC Coroners Service, 2022), while opioid-related deaths are at an all-time high in many provinces (Dryden, 2023). Pressing health concerns, along with unexpected deaths due to our environment and pandemics, continue to increase while the longevity phenomenon and the result of a massive Baby Boomer generation results in unprecedented numbers on the cusp of dying and requiring medical assistance.
In addition to accidental and unexpected deaths, our demographics dictate that there will be a large spike in deaths as the Baby Boomer generation faces mortality. In 2022, Statistics Canada reported that over 9.2 million adults living in Canada are over the age of 65 (Government of Canada, 2022), and though 45,995 individuals passed away in BC in 2022 (BC Vital Statistics Agency, 2023), the number of annual deaths in BC will double over the next few decades (BC Vital Statistics Agency, 2020). This suggests that more and more individuals will be considering MAID to address their aging and healthcare concerns. This also supports the argument that more helping professionals are required to coach and assist those who are facing death.
This inevitable wave in deaths is not supported within the existing healthcare infrastructure, which may cause some to consider MAID more readily as a viable option. Many hospices throughout the country have reported a significant increase in demand, outstripping their ability to provide professional and volunteer services in a timely fashion. There are 27,931 long-term care beds in the province of BC, along with 10,500 hospital beds, and a mere 260 hospice beds (Office of the Seniors Advocate, 2021). The existing limit of beds for care in BC and across Canada will be outstripped by the demand that 9.2 million Baby Boomers will present.
The Ebb and Flow of Opinions
This wave of reality will provide more opportunities and requests for MAID, which may increase the polarizing perspectives and political rally cries that surround it. According to the findings from an Angus Reid Institute (2022) poll, “three-in-five Canadians (61%) say they support the current MAID law in Canada, which allows a patient to request the treatment under certain circumstances but without facing foreseeable death” (para. 2). The original bill concerning MAID was passed in 2016 with 55 percent of Canadians stating “support” or “strong support.” In 2021, this similar affirmation had risen to 60 percent, resulting in a 5 percent increase. Whereas, in 2016 only 17 percent were “opposed” or “strongly opposed,” by 2021 these positions grew to 28 percent. This reveals the mounting polarization of Canadians on this topic. Despite the increasing opposition to MAID, largely influenced by religious beliefs, many Canadians still utilized this service. During this time (2016-2021), Canadians accessing MAID had multiplied, resulting in over 31 thousand people receiving assisted dying, including more than 10 thousand in 2021 alone. The trend is increasing exponentially. Two out of five Canadians (43%) consider this increase a success in providing people agency over their end-of-life decisions, whereas one in four (25%) disagree, noting concerns of overuse or abuse. Presently, it is estimated that one in seven Canadians have been touched by MAID through a close friend or family member choosing to end their life in this way (Angus Reid Institute, 2022).
MAID as a social phenomenon is, or will soon become, unavoidable. Family members, friends, and faith communities will all be confronted with its practical, philosophical, and ethical dilemmas. It would be easy to get lost in the philosophical and political debates and become distracted from the growing need for care, counsel, and coaching to be provided for those considering MAID, which is real and increasingly prevalent.
The Rising Tide
In 2018 the Canadian government published its “Framework on Palliative Care in Canada,” which stated that the number of Canadians that are dying from chronic illness, such as cancer, heart disease, organ failure, dementia, or frailty is increasing. It further outlined, “By 2026, the number of deaths is projected to increase to 330,000, and to 425,000 by 2036” (Health Canada, 2O23). The government then identified that Canadians want palliative care to occur at home, but that over 60 percent of Canadians are dying in hospital. The reasons Canadians want to die at home are compelling and most agencies agree this preference needs to be supported.
The term “palliative care” emerged in Canada in the mid-1970’s, initially as a medical specialty serving primarily cancer patients in hospitals. However, since then, the scope of palliative care has expanded to include all people living with life-limiting illness. With an aging population, demand for palliative care, delivered by a range of providers, has grown. Palliative care is an approach that aims to reduce suffering and improve the quality of life for people who are living with life-limiting illness through the provision of: pain and symptom management; psychological, social, emotional, spiritual, and practical support; and support for caregivers during the illness and after the death of the person they are caring for.
Palliative care should be person- and family-centred. This refers to an approach to care that places the person receiving care, and their family, at the centre of decision-making. It places their values and wishes at the forefront of treatment considerations. In person- and family-centred care, the voices of people living with life-limiting illness and their families are solicited and respected. Palliative care can be provided in conjunction with other treatment plans and is offered in a range of settings by a variety of health care providers including, but not limited to, doctors, nurses, nurse practitioners, pharmacists, social workers, occupational therapists, speech therapists, and spiritual counsellors (Health Canada, 2023).
The necessity for counsel and coaching through end-of-life scenarios is a growing need, which has been noted by academic and wellness communities. In British Columbia, death doula programs–trainings for professionals who provide continuous physical, emotional and informational support– are not new. Several colleges and universities, including Vancouver Island University (VIU) and Douglas College have offered death doula certificate programs for many years. However, most offerings are short-term programs and introductory, ranging from five days to six weeks. Given the short duration of these trainings, concerns arise on whether participants are receiving sufficient training to acquire the skills necessary to provide the empathetic coaching and facilitation competencies required to help individuals and their family members deal with challenging end-of-life considerations. Rhodes Wellness College is inaugurating a robust end-of-life coaching program consisting of 24 weeks of immersive and experiential learning that seeks to leverage the wisdom of Dr. Wong’s existential positive psychology. Graduates from this program will be trained to work side-by-side with other health professionals and will, most importantly, support those in the dying process, as well as their loved ones, with loving, professional guidance so that their wishes and needs can be honoured and supported. Through this program, the College aims to help make the transition from life to death navigable with honour and dignity rather than with fear and hopelessness.
Navigating the Currents
With the growing demand of an aging population, limited access to healthcare services and, as a result, increasing consideration of utilizing MAID, end-of-life coaches will be incredible assets to assist people as they process their end-of-life journey. However, to do so effectively, it will be imperative that one remain client-centred and to suspend one’s own bias and view on this potentially charged issue. End-of-life coaching is well suited to aid in this process of assisting people as they navigate life’s final stages, including when considering MAID, due to the required client-centered approach, as stated by the Canadian government (Health Canada, 2023).
Life coaching draws substantively upon the influence of Carl Jung and his emphasis on individuation, the shadow, symbolism, spiritual archetypes, and transpersonal consciousness. It also leans heavily on the work of Viktor Frankl as an exemplar of intention and finding meaning. Carl Rogers’ client-centered approach is another cornerstone of end-of-life coaching. His terms of “unconditional positive regard” and “humanistic psychology” are woven throughout the coaching material, as well as his practice of listening, reflecting, and paraphrasing, while valuing silence and the sacred (William & Menendez, 2015). These influences centre the coaching process in the client, thus allowing the coach to suspend his or her judgments and biases, be it on MAID or other issues. As William & Menendez (2015) specify:
From this perspective, the client is viewed as the expert on his or her life and is believed to be competent, capable, creative, and resourceful. At the same time, the coach is the expert on the coaching process only. This means that the coach’s responsibility is to ‘discover, clarify, and align with what the client wants to achieve, encourage client self discovery, elicit client-generated strategies and ideas, and hold the client responsible and accountable. Through the process of coaching, clients deepen their learning, improve their performance, and enhance their quality of life’ (ICF Code of Ethics 2005). Thus, coaching is a learning and developmental model with an emphasis on creating awareness so that clients can choose outcomes that promote their growth and development while attaining what they believe are the qualities of a fulfilling life. (p. xxx)
According to the International Coaching Federation core competencies, coaches are to place their own agenda aside and remain fully client-centred to assist the client in future choices, grounded in the client’s own values. The emphasis, and centering belief, is that the client is the expert of their own life and holds the values and perception of meaning within oneself with which to align. This client-centred approach is displayed in Rhodes’ (2023) competency practices of a coach, which acknowledges and supports:
- the client’s expression of feelings, perceptions, concerns, beliefs and suggestions
- client autonomy in the design of goals, actions, and methods of accountability
- that clients are responsible for their own choices
Therefore, the goal of coaching is to walk alongside a client to help clients explore their fundamental beliefs and values and, thus, empower the client to make their decisions based on those core elements of one’s being. The guiding belief of coaching is that the client is the authority of one’s life. Rather than imposing external beliefs and convictions, the coach aids the client to embrace personal agency and move forward in alignment with the client’s own values.
Here, once again, we find the efficacy of Dr. Wong’s existential positive psychology (PP 2.0) and its cross-disciplinary applicability (Wong, 2011). An end-of-life coach, operating with a PP 2.0-informed lens, will be far more equipped to process end-of-life strategies with clients, particularly when pertaining to MAID. Wong’s dual-system model confronts the dark sides of the human experience, including death, for the purpose of transformation toward a meaningful life today (Wong, 2012). Wong elaborates on this through his meaning-management theory (MMT), where he explicates, “Meaning management capitalizes on the human capacities for awareness, reflection, imagination, symbolizations, self-transcendence, creativity, narrative construction, and all sorts of meaning-based processes” (Wong, 2008, p. 70). It is precisely this focus that can inform coaches in being fully present to their clients, frame powerful questions, and listen deeply (Williams & Menendez, 2015). Thus, utilizing integrative meaning therapy (IMT) (Wong & Yu, 2021), offers the guiding schematic coaches can use to assist their clients as they consider their end-of-life care and strategies (Wong & Tomer, 2011).
An essential element in the coaching process is to assist clients in identifying their values and beliefs. Core beliefs are often held as absolute truths which direct a person’s function, both consciously and unconsciously. A coach’s task, through deep listening and powerful questions, is to help the client make sense of their core beliefs and how they may, or may not, be serving them (Rhodes, 2023). As Wong and Yu (2021) indicated, “good palliative care should include palliative counseling, which deals with psychological and spiritual issues related to suffering and dying, such as religious beliefs” (p. 9). Effective end-of-life coaching can play a critical role in providing this type of care that listens to and draws out one’s deep beliefs and existential perspectives, especially pertaining to death. End-of-life care is burgeoning with complexity and therefore, “requires teamwork, which may include physicians, nurses, psychologists, and pastoral care chaplains. When the team uses their collective resources and adopt a holistic approach that recognizes the importance of spiritual-existential dimension in patients and their families, it will benefit both the healthcare professionals and their patients” (Wong et al., 2018, p. 196). End-of-life coaches provide a crucial role to that care team as they operate from a PP 2.0 lens and utilize IMT.
IMT in palliative care focuses on more than “cognitive reframing or rationalization,” but rather offers an existential shift toward finding meaning and experiencing transcendence (Wong & Yu, 2021, p. 11). Wong elaborates on this by clarifying the concept a meaningful life as one of purposeful responsibility where one’s life is coherent, and joy is found through service to others. This correlates with life skills coaching that emphasizes balanced self-determined behaviour in which the client is called upon and empowered to take purposeful responsibility of oneself (Rhodes, 2023). Here, Wong’s PP2.0 informs and expands the coaching modality as “IMT seeks to awaken the client’s sense of responsibility and meaning, and guide them to (a) achieve a deeper understanding of the problems from a larger perspective and (b) discover their true identity and place in the world” (Wong & Yu, 2021, p. 15). It is just such awareness that coaching desires to elicit (Williams & Menendez, 2015), and it is from such awareness that clients may make enlightened end-of-life choices that will align with their deepest values.
Guiding Safely to the Harbour
Further parallels are identified when applying end-of-life coaching practices integrated with IMT practices. Coaching emphasizes global (intuitive) listening, somatic connection, moments of silence, the I-Thou relationship (see Buber, 1970), deep compassion, and connection to values (Williams & Menendez, 2015). These practices are built on the holistic model of care attending to the mental, emotional, physical, and spiritual well-being of the client (Rhodes, 2023). IMT palliative care practices parallel these themes, noting (as end-of-life coaching affirms), that “the transformative approach to spiritual care is based on what you say and do with patients rather than what you do to the patients” (Wong & Yu, 2021, p. ?; italics added). Specific IMT practices include the following:
- The healing silence—listening to the inner voice.
- The healing touch—touching the heart and soul.
- The healing connection—establishing an I–You relationship.
- The healing presence—providing a caring, compassionate presence.
- The healing process—nurturing spiritual growth.
These caring actions guide one toward self-transcendence, which is the penultimate way to transcend the material world and truly prepare one for death (Wong & Yu, 2021). Such level of care is needed as patients consider MAID and speaks to the importance for end-of-life care to be provided by health and wellness professionals who are fully informed and well practiced in meaning-making care and therapy. It is this realization that leads Wong et al. (2018) to conclude, “we argue that better end-of-life care education is needed in medical schools, residence training, and continued education for practicing physicians. This is important not only because of increased demand for hospice and palliative care, but also because of increased demands for physician-assisted death in many countries” (p. 196). The pragmatic need must not drive policy or dampen care. A humanistic approach that honours the client as a sentient being with a life of meaning must guide both policy and practice.
Medical assistance in dying elicits strong emotions and opinions. However, to best serve one’s client, end-of-life coaches will do best to apply the client-centered approach with a PP 2.0-informed lens and IMT practices. It is this informed practice that will aid self-transcendence, which is “‘the best possible help’ for palliative care patients because it broadens their values, opens the door for them to discover something worthy of self-transcendence, and it enables them to find meaning and happiness” (Wong & Yu, 2021, p. 16). Coaching with this lens and practice enables the end-of-life coach to remain focused on the guiding principle of meaning-making and empowering the client through personal agency that aligns with their inner values and prepares them for life’s final stage.
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