physician-assisted death · physician-assisted death, but will continue to provide all other care....
TRANSCRIPT
Physician-Assisted Death
50th Annual Mackid Symposium April 15, 2016
Eric Wasylenko MD CCFP MHSc
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Faculty/Presenter Disclosure
Any personal opinions expressed are my own and do not reflect official positions of any organizations I work with.
Relationships with commercial interests:– None– Contractor with AHS and with HQCA
Potential for conflict(s) of interest:
– No financial conflicts to report
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Faculty/Presenter Disclosure
• Other affiliations:
– Member Advisor, Vulnerable Persons Standard
– Member, CMA Committee on Ethics
– Clinical Lecturer, John Dossetor Health Ethics Centre, U of A
– Clinical Lecturer, Division of Palliative Medicine, Department of
Oncology, U of C
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Objectives
1. Highlight the SCC ruling, subsequent actions and implications
2. Provide an overview of AHS’ and the province’s efforts to date
3. Review some current operational challenges
4. Provide some resources for further information, reflection and
support
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Scenario #1 – Willing Provider Following a request for physician-assisted death from a patient , a willing
physician requests information regarding the mandatory eligibility criteria and support to assist his/her patient to explore the request
The willing physician has had a therapeutic relationship with the patient for > 5 years.
The patient is in the final stages of a life-limiting cancer. A team of cancer care specialists and palliative care specialists have been providing care along with the willing physician.
The patient is currently at home.
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Scenario #2 – Non-willing Provider
Following a request for physician-assisted death from a patient, a non-willing physician provider calls Health Link (811) for assistance.
Health Link provides the ZMD contact number and the non-willing physician contacts the ZMD office requesting support for the patient in the exploration of the request.
The non-willing physician has had a therapeutic relationship with the patient for > 5 years, as part of a team of specialists that have been providing care. However for reasons of moral conscience this physician will not participate in physician-assisted death, but will continue to provide all other care.
The patient is in the final stages of a life-limiting illness - ALS. There is no concern regarding the patient’s capacity or mental health status.
The patient is currently admitted to a non-participating acute care facility and wishes to be transferred home to die.
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Scenario #3 – Non-life limiting illness• The ZMD office receives a request for physician-assisted death from a
patient with a primary diagnosis of chronic depression.• The patient has been unresponsive to all conventional treatment (including
ECT) for > 10 years, has required multiple hospital admissions over the years and has attempted suicide numerous times.
• The patient has no other substantial medical illnesses.• The patient does not have a Primary Care physician. The patient does
have a team of Mental Health specialists providing care, however the patient’s condition remains unchanged and unresponsive to treatment.
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Scenario #4 – Complex Clinical Hx The ZMD office receives a request for physician-assisted death from the
following patient:– Quadriplegic for 15 years as a result of a traffic collision– Experiences frequent and very painful spasmodic events – Numerous hospital admissions related to frequent episodes of
pneumonia– Decubitus ulcers which have required surgical repair– Secondary diagnosis of depression.
The primary care physician has declared that she is a non-willing physician for reasons of moral conscience and will not participate in physician-assisted death, however will continue to provide other related care.
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Key messages (1)
• Still some uncertainty, but clarity is approaching
• Until June 6, 2016, AD is still illegal without a specific Court Order
• System has mobilized to meet commitments
• Access and mechanisms for AD can be achieved within proposed
laws and regulations
• Safeguards for vulnerability need to be advantaged
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Key messages (2)
• Actions arising from positions of moral conscience will be protected
as much as laws and regulations will allow
• Many resources are available
• We can continue to walk with our patients and walk with our
colleagues – response to suffering, wise guidance
• Opportunity to position and advocate for better palliative care
resources
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Information resources
• AHS Assisted-Death Preparedness website:– www.ahs.ca/pad
• CFPC – A Guide for Reflection on Ethical Issues Concerning Assisted Suicide and Voluntary Euthanasia
• Guidance documents from CPSA, other professions’ regulatory authorities, CMPA, CSPCP
• AHS Assisted-Death Preparedness Secretariat email:– [email protected]
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AHS Website
• For Public:
– “How Do I Access”; Public FAQ
• For Physicians/other providers:
– Process Map; Physician FAQ; links to regulatory body
advice documents
• Links to Other Resources including Palliative End Of Life
Care
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Covenant Health website
• http://www.covenanthealth.ca/newsroom/news-bank/news-events-bank/covenant-health-response-to-physician-assisted-death/
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Vulnerable Persons Standard
• www.vps-npv.ca
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Supports
• AMA Physician and Family Support Program 1-800-SOS-4MDS (767-4637)
• AHS Employee Family Assistance Program 1-877-273-3134
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Some useful reading
• Chochinov, HM. Secobarbital in Seattle-why lose sleep. Nat. Rev. Clin. Oncol. 2013.
• Byock, I. The Nature of Suffering and the Nature of Opportunity at the End of Life. Clinical Geriatrics Medicine. 1996; 12(2):237-5
• Sumner, LW. Assisted Death: A Study in Ethics and Law. Oxford University Press. 2011.
• McGee, A. Does Withdrawing Life Sustaining Treatment Cause Death or Allow the Patient to Die. Medical Law Review. 2014; 22(1):26-47. Oxford University Press.
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Some useful reading
• Reiff, David. Swimming in a Sea of Death: A Son`s Memoir. Simon and
Schuster, New York. 2008.
• Campbell, CS & Black, MA. Dignity, Death, and Dilemmas: A Study of
Washington Hospice and Physician-Assisted Death. J Pain and
Symptom Management. 2014; 47(1):137-153.
• Sweet, V. God’s Hotel: A Doctor, A Hospital, and a Pilgrimage to the
Heart of Medicine. Riverhead Books, NY. 2012.
• Fink, S. Five Days at Memorial: Life and Death in a Storm-Ravaged
Hospital. Crown Publishers, NY. 2013.
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Supreme Court of Canada ruling (Carter)
• In February 2015 the SCC declared certain sections of the criminal code
invalid (because the Court deemed them to be unconstitutional), relating to
the criminality of physicians aiding or counselling for suicide.
• The SCC then suspended that declaration for one year (until February 6,
2016) in order to give legislators and regulators time to put in place laws and
regulations, if they choose to do so.
• In January 2016 the SCC provided an extension to that declaration of
invalidity, of a further four months - to June 5, 2016.
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Eligibility criteria
The court issued a declaration (suspended for 12 months) that Section 241 and Section 14 of the Criminal Code were void insofar as they prohibited physician assisted death for a competent adult person who:
- clearly consents to the termination of life, and
- has a grievous and irremediable medical condition (including an
illness, disease or disability) that causes enduring suffering that is
intolerable to the individual in the circumstances of his or her
condition.” (Carter v. Canada (Attorney General). 2015. SCC5)
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SCC ruling also stipulated:
• Not exclusively for dying patients
• Did not distinguish between provision of self-administered
substance and a provider directly administering a substance
• Affirmed the right of a patient to refuse standard of care treatments
• Said physicians need to be involved (silent regarding other
providers)
• Charter rights of physicians need to be reconciled with charter
rights of patients
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SCC update ruling
• The Court extended the period of stay of the original decision until
June 5, 2016, for more preparation time
– blanket prohibition invalid as of June 6, 2016
– interim period – application to Superior Court for a judicial grant
for assisted-death
– Quebec exempt as Bill 52 already enacted
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What the SCC asked to be put in place
• Reasonable access to assisted-death for eligible Canadians
• Reconcile the rights of physicians to object for reasons of
conscience, and thereby not participate
• A strong system of safeguards to protect vulnerable persons
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Terminology
• Physician-assisted death includes both:
– euthanasia and assisted suicide
• Descriptive terminology can be summarized as:
– Patient requested, state sanctioned, chemically induced death
facilitated by a physician
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Federal and Provincial work
• Federal – expect to see a draft bill sometime in April/16
• Provincial – AH just completed public consultation– will respond to the Federal proposal by adding legislation or
regulations
– Local Regulators and health system operators will put in place policies and resources that are compliant
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Provincial Superior Courts - since Feb/16
• AB superior court is Court of Queens Bench
• ON and BC Courts have put out guidelines regarding what the
Court wants to see for the applications.
• Manitoba has agreement regarding protection from criminal
prosecution for select multi-disciplinary group of ‘facilitators’
• Quebec AG declared that participants would not be prosecuted if
operating within the law
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Quebec Bill 52
• MD consult
• No cooling off period
• Termed as medical aid in dying
• Commission for oversight – assesses compliance with regulations,
report to College if breach
• Duty to refer
• Participation not mandatory
• Obligation for continuity of care
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What does Bill 52 (Quebec) say, in essence?
• People have a right to exemplary end of life care
• That care ought to seek to preserve dignity and autonomy for the individual
• Assisted death and palliative sedation are part of the full spectrum of end
of life care
• All institutions should provide or make available the full spectrum of end of
life care options
• An advance medical directive mechanism, including binding force
provisions, must be in place
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Quebec
• Physician must attend
• Physician takes two drug kits, in case of failure of one
• Euthanasia only
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Manitoba
• Appears that they will allow euthanasia only at the outset
• Navigator resource team that also provides AD (WRHA)
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Alberta Health Services
• Secretariat created in Oct, 2015 to craft a mechanism in order for
AHS to be prepared
• Steering Committee, 6 expert panels advising us
• Consultations, surveys, patient engagement
• Development of policy, Interim Clinical Directive
• Issues identification and resolution
• Harmonized work with AH, Regulatory Colleges, Universities
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Collaboration
Engaging internal and external stakeholders:• AHS staff; physicians; Medical Affairs• AHS Leadership groups (ZMACs, COEC, QSEC, PPEC; ELT)• Patient and Family Advisory Group; Alberta Clinician Council• Alberta Health / Justice• Covenant Health, Hospices • Regulatory Bodies:
– CPSA; Tri-Nursing Colleges (CARNA, CLPNA, CRPNA); AB College of Pharmacists; Paramedics; Psychologists; Social Work; EMS; etc.
• Employee Family Assistance Program; Physician Family Support Program• Canadian Nursing Protective Society; CMPA• U of Calgary; U of Alberta
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Phases of AD for the clinician and patient
• Patient requests information or requests access to AD• Inform, explore with the patient, including options for needed care• Assess eligibility
- compliance with criteria - competence- vulnerability conditions
• Make a decision with the patient, achieve consent• Provide AD if that is the decision• After-care, bereavement, reporting
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Phases simplified
• Respond to• Inform• Assess• Reflect and decide with
• Then possibly, provide Assisted-death• Bereavement, after-care and reporting
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Navigation (1)
• AHS resource teams
– Navigator, operations lead and physician lead
• Access through Zone Medical Director (ZMD)
– May be linked zones
• Access directly, via Health Link, through ZMD
• Key concept: ‘walk with’ the patient, family and care team, through
the necessary steps and forms, assist with access to required
consultants and potentially, access to providers
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Navigation (2)
• With this mechanism, we believe we will:– support required access – Promote assessment for vulnerability – provide mechanisms for available consultations – allow transfers when required– provide appropriate access to drug protocol– allow physicians and teams to maintain trusted connection with
patients– provide room for objections for reasons of moral conscience
without abandonment
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Processes
• Process maps
• Support mechanisms, including psychologic support for clinicians
• Pharmacy protocol
• Reporting to Medical Examiner’s office
– only ME can sign these Death Certificates
– reportable death
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Drugs
• protocol not currently for general distribution
- will review verbally
• consent for conversion to iv if required
• drugs provided to physician, Rx written for patient
- chain of custody
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Drugs
• oral, self-administered
- classes, purposes, order of administration
• iv, physician-administered
- classes, purposes, order of administration
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Issues (1) – public policy and professions
• Harmonization within and external to AHS
• Training, credentialing and privileging
• Non-participating for reasons of moral conscience and for other
reasons
– Individuals
– Organizations/sites
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Issues (2) – provider issues
• Payment for drugs and services
• Availability of drugs and supplies
• Protection for non-physicians
• Confidentiality of service provision
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Issues (3) - access and safety
• Transfers
• Sites of delivery
• Attendance by physician
• Fail-safes
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Issues (4) – current controversies
• Mature minors, not-yet competent and never-competent children
• Advance directive eligibility
• Psychiatric illness
• Non-terminal conditions
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Issues (5) – dispelling myths
• Withdrawing and withholding interventions and AD
• Palliative sedation and AD
• Autonomous decision by a patient does not automatically confer a
positive obligation on a physician to provide a particular act
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Key messages repeated (1)
• Still some uncertainty, but clarity is approaching
• Until June 6, 2016, AD is still illegal without a specific Court Order
• System has mobilized to meet commitments
• Access and mechanisms for AD can be achieved within proposed
laws and regulations
• Safeguards for vulnerability need to be advantaged
45
Key messages repeated (2)
• Actions arising from positions of moral conscience will be protected
as much as laws and regulations will allow
• Many resources are available
• We can continue to walk with our patients and walk with our
colleagues – response to suffering, wise guidance
• Opportunity to position and advocate for better palliative care
resources
