Medical Assistance in Dying (MAiD) What the pharmacist needs to know

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Andra Cummings
5 years ago
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1 Medical Assistance in Dying (MAiD) What the pharmacist needs to know

2 Scenario You are on duty at a community pharmacy in Brantford, busy working through a couple of discharge prescriptions that were faxed over by the Brantford General Hospital. Your thoughts are interrupted by the technician, a physician is on the line to give a verbal prescription. The local physician tells you that he intends to write a prescription for a lethal dose of propofol to end a patient's life. Your mind quickly get overwhelmed with various thoughts.

3 Scenario Situations such as this already occur in many countries and more recently in provinces across Canada. These raise a number of important considerations for pharmacists, including patient counseling issues, legal requirements, moral and ethical concerns, and possible consequences for refusing to dispense the medication. So far the major focus has been physicians and patients. However, in most cases a pharmacist plays a large role in Medical Assistance in Dying.

4 Lessons Learned My Values: What do I feel about assisted dying? Where do my feelings come from? Would I want this option for myself, my family, my patients? What are my fears and hopes? If a patient approach you about MAID, how would I respond? Other people s values Legal framework and eligibility criteria Organizational response

5 MOVING FORWARD UNDERSTAND Yourself The facts about MAID CONNECT TO Your values The patient story Your resources ACT WITH Integrity Compassion

6 BILL C-14: MEDICAL ASSISTANCE IN DYING (MAID) Who is eligible? mentally competent adults (18yo) eligible for health services funding in Canada grievous and irremediable medial condition be capable to make informed decision considering all options, including palliative care provide voluntary consent (through written request and at administration) NOT included: non-terminal conditions, mature minors, substitute decision-making and advance directives

7 Grievous and Irremediable Medical Condition? serious and incurable illness, disease or disability an advanced state of irreversible decline in capability that illness, disease, disability or state of decline causes patient enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable and natural death is reasonably foreseeable; does not require a prognosis of a specific length of time

8 WHO CAN ADMINISTER? MD, NP, Patient (self-administration) Permits conscientious objection, emphasizes obligation for effective referral

9 College of Physician and Surgeons of Ontario (CPSO) Outlines Bill C-14 requirements and reiterates eligibility criteria Emphasizes compassionate response to requests Careful management of conscientious objection, specifically effective referral Provides process map No specific direction re: drug protocol, assessment process, etc.

10 Lessons Learned: CPSO Good record keeping essential HCP in the facility where the patient has requested MAID can be a witness to patient s written request as long as this individual: does not own the facility; and is not directly involved in the patient s health care or personal care (consult your Risk/Quality of Care department for direction) Care coordination is essential, esp. w pharmacy

11 College of Nurses of Ontario (CNO) Outlines NP role in assessment, provision, documentation Supports RN and RPN role in providing nursing care, patient/family support, IV access, and assisting MD/NP in MAID RN/RPN may not administer medications for assisted dying or encourage MAID Nurses must not communicate conscientious objection to clients; transfer care to willing provider

12 Ontario College of Pharmacists (OCP) Emphasizes RPh and RPhT supportive scope If pharmacist is conscientious objector, must provide effective referral to a non-objecting alternate provider in a timely manner Must make referral for information to MD or NP Responsible to ensure eligibility criteria met/documented Emphasizes safe dispensing and disposal

13 Connect to the Values Ground yourself in your values What legacy does the patient (and family) want this conversation to have? What legacy do you want this conversation to have for you?

14 Connect to the Patient Story A requests for assisted dying is an invitation into story Requires curiosity, openness and narrative competence What might the patient really be saying? What is motivating the request? What is the feeling behind it all? The danger of one story

15 Connect to Resources Organizational policies and procedure Supports to address patient suffering: Supports for you and your team

16 Person-centered, Values-based, Evidence-informed

17 Understanding MAiD Through an Ontological Lens Ontology is the study of being The basic structure of all being is dialectical i.e., there is a self in dialogue with its environment The vocational self in the field of medicine is the practice of self in dialogue with a limit setting environment that includes the ethics and accountability of the profession and the needs/demands of persons receiving care

18 Understanding MAiD Through an Ontological Lens Self Self Values (incl. ethics and morals) Beliefs Experiences of life Family of origin Culture(s)

19 Understanding MAiD Through an Ontological Lens Self & Environment Self Values (incl. ethics and morals) Beliefs Experiences of life Family of origin Culture(s) Environment Other selves w/values, experiences of life and story Professionaccountabilities and ethics

20 Understanding MAiD Through an Ontological Lens-Changing Environ Self Values (incl. ethics and morals) Beliefs Experiences of life Family of origin Culture(s) Environment Legal system-change Profession-change i.e., we can aide individuals seeking MAiD / organizational change / change in prof. accountabilities

21 Understanding MAiD Through an Ontological Lens-After Adjustment Adapted Self Culture(s) Beliefs Values (incl. ethics and morals) Experiences of life Family of origin Changed Environment Other selves & choice Profession-adjusted accountabilities & ethics

22 How do I feel about this? Questions: 1. How do I feel about MAiD? 2. How do I feel about being a part of the MAiD process? 3. What factors might influence how I feel about this? 4. What emotions am I aware of when I think about MAiD this way (it may be helpful to think of dominant emotions: fear/sadness/anger/happiness)? 5. How do I make sense of MAiD? As these questions are answered we may get a sense about 6. How willing am I to fill medication orders; transport meds?

23 Is this legal? Historically, it has been a crime in Canada to assist another person in ending his/her own life. Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) received royal assent on June 17, On June 17, 2016 the federal government enacted amendments to the Criminal Code of Canada (the Criminal Code ) to include circumstances under which medical assistance in dying is permitted.

24 Is this legal? Pharmacists and pharmacy technicians are now exempted from criminal liability when dispensing a prescription that is written by a medical or nurse practitioner in providing medical assistance in dying in accordance with applicable federal legislation, provincial or territorial legislation, standards, policies or guidelines, is protected from criminal liability.

25 Eligibility All Ontarians are eligible, pursuant to a valid prescription and provided that the patient meets the specified eligibility criteria for MAID. 1. Be eligible for publically funded health services in Canada (ie have OHIP). 2. Be at least 18 years of age and capable to make decisions regarding health. 3. Have a grievous and irremediable medical condition. 4. Make a voluntary request for medical assistance in dying that is not a result of external pressure. 5. Provide informed consent after being informed of the means that are available to reliever their suffering, including palliative care.

26 Pharmaceutical Thought Process Indication Effectiveness Safety Cost

27 Indication Barbiturate and Derivatives Secobarbital Pentobarbital Opioids and Benzodiazepines Morphine Sulfate Hydromorphone Midazolam Neuromuscular blockers Rocuronium Bromide Cisatracurium Besylate

28 Effectiveness Secobarbital and Pentobarbital not available in Canada. For oral meds, time to death post ingestion can range from minutes to hours, sometimes even longer. IV Medication, minutes.

29 Cost ODB covers the full cost of MAiD kits and can be billed electronically for ODB patients. Intervention code PS : (Professional Care Services) Product Identification Number (PIN) Valid Pharmacist ID Professional Fee: The actual acquisition cost of the MAID kit

30 Cost Non-ODB eligible patients are billed manually (paper) as they need three intervention codes. Patient Gender: F = female; M = male Patient Date of Birth: Valid YYYYMMDD Patient s Ontario Health Card number Intervention codes: PS: Professional Care Services ML: Established eligibility coverage (i.e., 1 day of the Plan S coverage) MO: Valid Claim value $500 to $ Carrier ID: S Product Identification Number (PIN): see table above for the list of PINs Valid Pharmacist ID Professional Fee: The actual acquisition cost of the MAID kit

31 Am I authorized to dispense? All pharmacies/pharmacists in Ontario are authorized to dispense medications used for MAiD.

32 Do I have these drugs? All drugs that form part of the ODB funded MAiD kits can be ordered through your drug distributor. For the rare occasions when you are having trouble acquiring these medications, you can contact the BGH inpatient pharmacy.

33 MAiD Kits PIN PIN Description Contents Amount Reimbursed MAID intravenous (IV) Kit with Supplies MAID IV Kit (backup) with Supplies Midazolam 1mg/mL Lidocaine 2% (without epinephrine) Magnesium Sulfate 500mg/mL Propofol 10mg/mL Cisatracurium Besylate 2mg/mL Rocuronium Bromide 10mg/mL Sodium Chloride (NaCl 0.9%) Syringes and tubes $ Same as above $ Acquisition Cost Midazolam $87.33/box $8.73/dose e.g. DIN (Sandoz), McKesson Lidocaine $11.83/box $5.59/dose e.g. DIN (Alveda), McKesson Magnesium $149.19/box ~$30/dose e.g. DIN (Fresenius Kabi), McKesson

34 MAiD Kits PIN PIN Description Contents Amount Reimbursed MAID IV Kit with Phenobarbital and Supplies MAID IV Kit (backup) with Phenobarbital and Supplies Midazolam 1mg/mL Lidocaine 2% (without epinephrine) Magnesium Sulfate 500mg/mL Propofol 10mg/mL Phenobarbital 120mg/mL Cisatracurium Besylate 2mg/mL Rocuronium Bromide 10mg/mL Sodium Chloride (NaCl 0.9%) Syringes and tubes $ Same as above $ Acquisition Cost Phenobarbital $142.73/box $356.83/dose e.g. DIN (Sandoz), McKesson

35 MAiD Kits PIN PIN Description Contents Amount Reimbursed MAID Self- Administration Kit (Hydromorphone/ Morphine) MAID Self- Administration Kit (Phenobarbital) Metoclopramide 10 mg Ondansetron 8 mg Propranolol 40 mg Morphine Sulfate (liquid) Morphine Sulfate 30 mg Hydromorphone 1 mg/ml liquid Hydromorphone 8 mg Metoclopramide 10 mg Ondansetron 8 mg Phenobarbital 20 g Chloral Hydrate 20 g Morphine Sulfate 3 g Haloperidol 5mg/mL $ $250.00

36 Other drugs Health Canada s Special Access Programme (SAP)

37 Acquisition Cost vs Reimbursed ODB: You are at full liberty to charge the maximum reimbursed amount. No questions asked. Me: But what if the acquisition cost is less. ODB: We will pay the full amount if you bill it. If you want, you can bill less. Me: Any legal ramifications or future audit issues if there is a mismatch? ODB: No.

38 Counselling Oral medication counselling must be offered to the patient or patient's agent and provided in person. The pharmacist can offer to provide counselling over the telephone. Instruct to take an antiemetic about one hour before ingesting oral meds to prevent nausea and vomiting. If vomiting occurs, instruct to contact ordering physician. If they decide not to end their life post ingestion, instruct them to contact 911. Unused medications should be brought back to the pharmacy for disposal.

39 Record keeping Same as any other prescription

40 Questions

Nursing Contribution to End-of-Life Care Decisions and Medical Assistance in Dying in Canada

Nursing Contribution to End-of-Life Care Decisions and Medical Assistance in Dying in Canada Josette Roussel, RN, MSc, M.Ed. Senior Nurse Advisor Canadian Nurses Association Outline Why did CNA developed