The Current Status of Medical Assistance in Dying

PRESENTATION TO 62nd ANNUAL

SCIENTIFIC ASSEMBLY September 30, 2016

Bryan Salte

Associate Registrar

Presentation Outline

Criminal Code Provisions The new legislation Unanswered questions Activity in Saskatchewan CPSS Policy

The Criminal Code

241. Every one who (a) counsels a person to commit suicide, or (b) aids or abets a person to commit suicide, whether

suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.

14. No person is entitled to consent to have death

inflicted on him, and such consent does not affect the criminal responsibility of any person by whom death may be inflicted on the person by whom consent is given.

Bill C-14 – Eligibility for MAID

Eligible for Canadian Health Services or will be eligible after a waiting period;

They are 18 Capable of making decisions about their health Have a grievous and irremediable medical

condition Have requested MAID which is not as a result of

external pressure Have given informed consent to MAID

Bill C-14 – What is “grievous and irremediable?

Serious and incurable illness, disease or disability;

An advanced state of irreversible decline in capability

Enduring physical or psychological suffering that is intolerable to the individual caused by the illness, disease, disability or state of decline;

The suffering cannot be relieved under conditions that they consider acceptable; and

Their natural death has become reasonably foreseeable without a prognosis necessarily having been made as to the specific length of time that they have remaining.

Bill C-14 – MAID requirements

Patient must sign a request before two independent witnesses

Two physicians, two nurse practitioners or one of each, who are independent of each other, must confirm their opinion that the patient meets MAID criteria

10 day waiting period unless death or loss of capacity is imminent

Pharmacist must be informed the purpose of medication prescribed is MAID

Bill C-14 – Before administering MAID

Physician or NP must: Be of the opinion the patient meets the MAID

eligibility criteria, including requirements for signed consent

Ensure the patient is advised that consent can be withdrawn

Provide the patient with opportunity to withdraw consent immediately prior to administration of MAID

Bill C-14 – Exemption from Criminal liability

Physicians or nurse practitioners who reasonably and in good faith conclude the patient meets MAID criteria

Anyone who aids a physician or nurse practitioner to administer MAID

Pharmacists who dispense medication pursuant to a MAID request

Individuals who assist a patient to self-administer MAID

Health care workers, social workers and others who provide information about MAID to a patient (counseling)

Bill C-14 – Some criticisms

Requirement for a reasonably foreseeable death Inability to have an advance directive Exclusion of mature minors Inadequate protections for vulnerable patients Inadequate protection of conscience:

(9) For greater certainty, nothing in this section compels an individual to provide or assist in providing medical assistance in dying.

Issues not resolved by the legislation

1) Will the provinces pass legislation related to MAID?

2) What will be the reporting or oversight requirements? (at present, in Saskatchewan, MAID deaths are reportable to the coroner)

3) Will MAID be available based on an advance directive?

4) Will MAID be available to mature minors?

Issues not resolved by the legislation

5) What are the expectations of physicians and other health professionals who are unwilling to participate in MAID?

6) Will there be detailed requirements for forms, standards, etc.? If so, who will establish them?

7) What is the impact of depression or other mental illness on a patient’s ability to consent to MAID?

8) Will a psychological or psychiatric evaluation be required? If so, for some patients? For all patients?

Issues not resolved by the legislation

9) How will the “system” identify patients deciding to undergo MAID under duress?

10)If MAID is self-administered – will MAID be available to patients who cannot self-administer?

11)If self-administered - What will be available for patients who are not sufficiently mobile to obtain a lethal prescription?

12)If MAID is self-administered must the medication be dispensed to a physician/nurse practitioner?

Issues not resolved the legislation

13) Must the physician be present at death? 14) Will the availability of supportive palliative care

have an effect on patient choice? 15) What will be placed on a patient’s death

certificate? 16) Will there be different regimes with different

requirements in the provinces and territories? If so, what are the implications?

Issues not resolved the legislation

17) Will a patient’s choice of MAID void their life insurance?

18) Will MAID be an insured service? 19) Will the cost of MAID medications be covered? 20) Will there be a structured referral system for

accessing MAID? 21) What obligation will institutions, including

faith-based institutions, have in relation to MAID?

Issues not resolved the legislation

21) If the medications are self-administered - Will there be a waiting period before a patient can pick up a prescription?

22) What reporting requirements will there be under provincial legislation to coroners/medical examiners if a patient accesses MAID? What obligation is there for a coroner/medical examiner to investigate in such circumstances?

Activity in Saskatchewan

The College of Physicians and Surgeons developed a policy – available on CPSS website.

The College is concerned about the qualifications of physicians to provide MAID – especially for self-administration. Is it a scope of practice change?

Activity in Saskatchewan

A committee with representatives of Government, CPSS, SMA, RHAs, other regulatory agencies, the Cancer Agency, etc. has been working to develop supporting documents. Those include: A process map Forms for patients and physicians Role descriptions “Scripts” to assist individuals to discuss MAID with

patients

Activity in Saskatchewan

RHAs have canvassed physicians about their willingness to participate in MAID

There has been discussion about government covering the costs of MAID medications and working on a referral service

The Coroner will be sending out a directive to coroners related to investigation of MAID deaths

Outstanding issues

Access to MAID – willing physicians and health care providers; availability in institutions

Availability of training – who will take it? Will it be an expectation for those who participate in

MAID?

Training/Education in MAID

The CMA Foundational online module: 1) To provide information on MAID for physicians, so they

can: a) understand what is involved, b) advise their patients, and c) make an informed decision about whether they should

include this in their practice. 2) This module is not expected to provide participants with

the training needed to provide comprehensive care at the end of life or medical assistance in dying.

3) The module is currently available

Training/Education in MAID

CMA Advanced face-to-face course: 1) To provide comprehensive education on topics

related to end-of-life care, as well as advanced practical training for physicians who are considering offering medical assistance in dying to their patients.

2) Course sessions will take place on September 15-17 in Vancouver and on November 3-5 in Toronto.

3) Completion of the online module is a pre-requisite for participation in the face-to-face course.

MAID IN OTHER JURISDICTIONS

Quebec

MAID has been legal since December, 2015 There are not yet published statistics but our information is that an estimated 400 patients will access MAID in the first year. About 64 of each thousand deaths are MAID deaths

IF RATES OF MAID FROM OTHER JURISDICTIONS ARE APPLIED TO

SASKATCHEWAN

2014-2015 - 9,798 deaths in Saskatchewan Estimate of number of MAID deaths annually in Saskatchewan based upon rates in: The Netherlands - 176 Quebec 63 Switzerland – 44 Oregon – 21

QUESTIONS OR COMMENTS?