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MedicalAssistanceinDying
RegulatoryPerspec6ve
AndréaFo6,LL.B,M.A.
CollegeofPhysiciansandSurgeonsofOntario
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Overview
1. Background
2. CPSO’swork
3. Prac6ce&ComplianceIssues
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Disclosures
• Nofinancialdisclosures
• Iam• HeadofPolicyatCPSO• LeadonCPSOMAIDfile
• IwasanaffiantinCPSOLi6ga6on
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BackgroundTheSupremeCourtofCanadafoundthattheCriminalCodeprohibi6onuncons6tu6onalbecauseitpreventedpa6entsfromgeQngassistancetoendtheirlife.
1FederalGovernment13Provincial/Territorial
13MRAs
MRAsdevelopguidancebasedonCarterfor‘interimperiod’
InterimPeriod
Federallawinforce
MRAsreviseguidancebasedonFederallaw
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MRAWork
MajorityofMRAshavearesourceonMAID→Reflectfederallaw
→Addressgaps/prac6ceissues:• Guidingprinciples• Interpreta6onofeligibilitycriteria• Conscien6ousObjec6ons• DrugProtocols&Prescribing• RecordKeeping&documenta6on
Legalmandate:Regulatetheprofessiontoprotectandservethepublicinterest
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Ontario
MinistryofHealthandLong-TermCare
Guidelines,CodeofEthics,StandardsonMAID
• Setoutrequirementsoffederallegisla6on
• Prac6ceissues• Conscien6ousobjec6ons• Prescribinganddrugsissues• documenta6on
OntarioCollegeofPharmacists
CollegeofNursesofOntario
• Drugcosts• BillingCodes• CareCoordina6on:informa6on,referrals
• OntarioCollegeofFamilyPhysicians• OntarioHospitalAssocia6on• CanadianMedicalAssocia6on• JointCentreforBioethics-UofTorontoge
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CPSO’swork
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MAIDpolicy
Prac6calDirec6on:ü ProcessMapü DrugProtocols
FillsGaps:ü RecordKeepingü Conscien?ousObjec?on:
Effec?vereferralobliga?on
Alignswith:ü FederalLawü Relevant
ProvincialLawsü RelevantCPSO
policies
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Step1:Pa6entInquiry
Step2:EligibilityAssessment(Clinician#1)
Step3:Pa6entRequest
Step4:Reminder-Pa6entcanrescind
Step5:Eligibilityconfirmed
(Clinician#2)
Step6:Reflec6onPeriod
Step7:Inform
Pharmacist
Step8:Confirmconsent&
ProvideMAID
Step9:Cer6fica6onofDeath
ProcessMap
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Prescribing&DrugProtocols
• Drugprotocols:Oregon,Quebec,Alberta• OngatedpartofCPSOweb• Resourcesforphysicians;nooneprotocolrecommended;prescribingasprofessionaldecision
• Protocolsavailable:members’onlypage
• Resources,noprotocolisrecommended
• Prescribingdecisions=makerofprofessionaljudgement
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Conscien6ousObjec6on:‘Effec1veReferral’
Referralcanbemadetoaphysician,nurseprac66oneroragency;
Physician,nurseprac66oneroragencymustbenon-objec6ng,accessibleandavailabletothepa6ent;Referralmustbemadeina6melymanner;pa6entmustnotsufferadverseoutcomeduetodelay
Objec6ngphysiciansdonothavetoprovideMAID;theydohavetoprovidean‘effec6vereferral’
Li6ga6on:June
2017
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Addi6onalResources
www.cpso.on.ca
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Prac6ce&ComplianceIssues
Public&PhysicianAdvisoryServices
• Calls,queriesfromtheprofessionandpubliconMAID
• Totalof681inquiriessinceApril2016
OfficeoftheChiefCoronerofOntario
• Oversightandcompliancemonitoringrole
• Trackingtrends,prac6ceissues
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PPASMAIDInquiries(sinceApril12016)
44%Physicians
56%Public
681Inquiriestotal
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PhysicianInquiries:TopIssues
0 20 40 60 80 100 120 140 160 180
Records/Documenta6on
DrugProtocols
Conscien6ousObjec6on
ReferralSupport
PhysicianTraining/Scope
Policy/LawInterpreta6on 32
19
38
161
20
16
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PublicInquiries:TopIssues
0 20 40 60 80 100 120
Opposi6ontoBill84
Effec6veReferral-Opposi6on
Informa6onforFamilyMember
SeekingWillingProvider
LekerstoGovernment
Opposi6ontoMAID 51
108
25
11
58
94
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• Documenta6on:lackof/insufficientdocumenta?on
• Witnesses:notindependent;notcontemporaneous
• Reflec6onPeriod:devia?onforalterna?vereasons
• DrugProtocols:lackofawarenessofprotocols
• Coordina6on&Communica6on:amongstproviders
Coroner’sOffice:KeyIssuesinPrac6ce
→Understandingandapplyinglawandpolicy
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Li6ga6on:Conscien6ousObjec6onFocus:‘Effec?veReferral’&s.2(a)ands.15(1)
Par6es:Date:June2017;decisiononreserve
SuperiorCourtofJus6ce(DivisionalCourt)
• Chris6anMedical&DentalSocietyofCanada
• CdnFedera6onofCatholicPhysicians’Socie6es
• CanadianPhysiciansforLife• 5individualphysicians(CPSO
members)
• CPSO
Intervenors
TwoCPSOpolicies:MAIDandHumanRights
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Li6ga6on:snapshot
Procedural• DoestheCharterapplytotheCPSO?
• Arethepolicies‘ultravires’CPSOjurisdic6on?
• WhatStandardofReviewisapplicable?
Substan6ve• Does‘effec6vereferral’
requirementviolatephysicianCharterrights?[s.2(a)ands.15(1)]
• Ifso,isitsavedbys.1?
• Is‘effec6vereferral’equivalenttoperformingobjec6onableprocedure?
• DoCPSOpoliciesplacephysiciansinjeopardy:adheretobeliefsorriskregulatorysanc6on?
Someques6onsadvanced…
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• Applica6on&Interpreta6onofEligibilityCriteria:‘advanceddeclineincapability’•‘reasonablyforeseeabledeath’
• AccesstoCare:ruralcentres,willingproviders
• Billing&Fees• OralDrugs:access&efficacy
• DataCollec6on&Oversight
• MatureMinors,MentalIllness,AdvanceRequests
OutstandingIssuesCareCoordina6onService
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www.cpso.on.ca