“Avoid serious and irreversible consequences”

On the phone, Nancy Lapointe’s voice breaks as she recalls what she whispered to the nurse who was preparing her to receive electroshocks for the umpteenth time: “Can you make a medical error, please, and just let me go? »

For five years, the blonde resident of Terrebonne had tried everything to eliminate depression. One drug on top of the other, electroshocks, in vain.^⁠1

“I wanted to be found to have incurable cancer, for medical assistance in dying (MAiD) to become possible for people with psychiatric disorders like me…”

Barring an about-face from Ottawa, Nancy Lapointe’s second wish will come true on March 17. Canadians devastated by unbearable and intractable mental suffering will then become eligible for MAID. As have been the case for several years now with people suffering from similar physical ailments and people at the end of their lives.

Three years ago, M^me Lapointe, however, stopped planning his disappearance. In 2020, an anesthetic that causes dissociation – ketamine – dissolved his suicidal thoughts in a flash, in a small room at the University of Montreal Hospital Center (CHUM).

To avoid a relapse, Nancy Lapointe had to take numerous doses of ketamine for a year. The time to obtain a rare operation, which improved the functioning of his brain more lastingly with an implant fixed near a nerve^⁠.

Today, the former respiratory therapist works in a new field. She who had nevertheless been declared disabled for life.

“Ephemeral, but extraordinary”

In recent years, a growing number of Quebecers have emerged from despair – at least temporarily – thanks to cutting-edge or experimental interventions. Ketamine, neuromodulation with or without implant, hallucinogenic substances…

Clinicians must absolutely “have recent and reliable data on all potential treatments” before facing new requests for medical assistance in dying, argue two psychiatrists in a case study published last fall.^⁠2

In less than two weeks, a cocktail of ketamine and intensive psychotherapy put an end to 15 years of continuous suicidal thoughts in a patient at the Jewish General Hospital in Montreal, explains the article by doctors Nicolas Garel and Kyle Greenway. After requesting medical assistance in dying twice, the sixty-year-old withdrew her request and moved closer to her son and grandchildren.

“Ketamine is not a miraculous intervention that everyone responds to, but for some patients it will be,” adds Dr.^r Nicolas Garel in interview.

The challenge is maintaining the magic, he warns. “Otherwise, the antidepressant effect only lasts a few days, after which the majority of people relapse. »

Giving ketamine non-stop is unthinkable. This would be too burdensome for the network and potentially too risky, as this substance can be addictive and then cause bladder damage and cognitive impairment. The star actor of the TV series Friends Matthew Perry drowned after drinking it.

With a safer and more comprehensive approach, 30% of people suffering from hyper-refractory depression treated with ketamine can return to work or a life worthy of the name, says Dr.^r Kyle Greenway, who refined this formula at the Jewish General Hospital with D^r Garel.

” It is enormous ! he said. Regardless of the treatment, such remarkable benefits are normally expected in only 2% or 3% of these types of patients. »

The D^r Paul Lspérance, who treated Nancy Lapointe at the CHUM, shares this enthusiasm. “In 25 years of practice, I have never seen anything that works like ketamine. The effect is fleeting, but it is extraordinary to observe! It allows certain people to escape a vicious circle – where they slept, stayed at home, isolated themselves, wanted nothing and therefore no longer had a source of self-worth. »

In general, the D^r Lspérance first tried transcranial magnetic stimulation, which allows the brain to be reactivated or soothed by delivering current to it, without electroshocks. With the help of his nurses, the program he directs has grown and created new ones in the region.

Life must have meaning

What should we do when a patient is offered a promising treatment, but insists that they be helped to die instead?

If he does not already have a long course of care, his suffering cannot be judged irremediable, a legal requirement. “Faced with a refusal, we explain to the person why they still have a chance of recovery and we let life continue, without forcing anything,” explains the D^D Mona Gupta, psychiatrist at CHUM and former president of the Expert Group on MAID and mental illness. Often, the person reconsiders their decision on their own, sometimes encouraged by their family. »

Even after decades of therapeutic failures, making a decision may remain difficult, because doctors fear that severe depression may induce excessive dark thoughts that cloud judgment.

Researchers in Toronto had the idea of ​​making these thoughts disappear with ketamine, to check if the desire to obtain MAID disappeared at the same time.^⁠3

Bioethicist Marie-Alexandra Gagné has nothing against such a “test”, provided that it does not serve as a shortcut and does not become a prerequisite for MAID.

Whether a patient suffers from cancer or depression, it doesn’t matter, respecting their limits and decision-making autonomy is essential, says M^me Gagné, who is also a clinical and organizational ethics advisor in the health network.

“Some people have tried almost every treatment over the years. They are exhausted, no longer believe in it, and we cannot force them to try all the experimental therapies, nor to continue to live with their suffering, hoping that science will find – perhaps – a cure in 10 years… »

“Sometimes dying really meets the needs and values ​​of the person asking for it, because they can no longer practice the activities that gave meaning to their life. »

1. Theelectroconvulsive therapy caused too much memory loss in M^me Lapointe, but this last resort intervention is effective in approximately half of patients.