The Current Status of Medical Assistance in Dying PRESENTATION TO 62 nd 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MAID eligibility criteria, including requirements for signed consent Ensure the patient is advised that consent can be withdrawn Provide the patient with opportunity to withdraw consent immediately prior to administration of MAID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 selfadministration. 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?