MAiD Overview 5/19/2020 I

Conflict of Interest NTRODUCTION No CoI

Not a member of advocacy group

Member of Provincial MAiD CoP Providing MAiD Not providing MAiD HEALTH AGING 101: MAID MAiD Presentation MAiD: Present & Future Not recommending or condemning MAiD

Peter Allatt, Bioethicist, Sinai Health

[email protected] 1 2

Overview G ERIATRICS

1. Present Situation 101

LAW 2. Q&A

3. Proposed Legislation MAID: PRESENT SITUATION PROPOSED Current Practice 4. Q&A

Peter Allatt, Bioethicist, Sinai Health

3 [email protected] 4 I

Part 1. Outline NTRODUCTION What has NOT changed

What has been clarified

What remains uncertain WHAT HAS NOT CHANGED What remains the same Who is requesting MAiD?

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Peter Allatt, Bioethicist 1 MAiD Overview 5/19/2020

Divisive W W HAT HAS NOT CHANGED HAT HAS NOT CHANGED

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Medical Assistance In Dying C Eligibility Criteria W RIMINAL CODE OF HAT HAS NOT CHANGED

a) The administering by a medical practitioner or Eligible for health services funded by a government of Canada

nurse practitioner of a substance to a person, at • Health card their request, that causes their death; Competent adult C

ANADA PROVISIONS • They are at least 18 years of age and capable of making decisions with respect or to their health

Informed consent b) The prescribing or providing by a medical • They give informed consent to receive medical assistance in dying

practitioner or nurse practitioner of a substance to Grievous and irremediable

a person, at their request, so that they may self- • They have a grievous and irremediable medical condition administer the substance and in doing so cause their own death. Voluntary request • They have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure.

Criminal Code, RSC 1985, c C-46. s241.1 http://www.canlii.org/en/ca/laws/stat/rsc-1985-c-c-46/latest/rsc-1985-c-c-46.html 9 Criminal Code, RSC 1985, c C-46. s241.2 (1) http://www.canlii.org/en/ca/laws/stat/rsc-1985-c-c-46/latest/rsc-1985-c-c-46.html 10

Grievous and irremediable medical condition W MAiD Process C RIMINAL CODE OF HAT HAS NOT CHANGED A person has a grievous and irremediable medical condition if they meet all the following criteria: • Talk to HCP Reflect • Talk to family

a) they have a serious and incurable illness, disease or • Written disability; C Request • 2 witnesses ANADA PROVISIONS b) they are in an advanced state of irreversible decline in capability; c) that illness, disease or disability or that state of decline Withdraw Ax. #1 • MD/NP causes them enduring physical or psychological suffering Request 10 that is intolerable to them and that cannot be relieved Clear under conditions that they consider acceptable; and Withdraw Days Ax. #2 • MD/NP d) their natural death has become reasonably foreseeable, Request taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining. ConsentWithdraw• Written Request• VerbalMAiD

Criminal Code, RSC 1985, c C-46. s241.2 (2) http://www.canlii.org/en/ca/laws/stat/rsc-1985-c-c-46/latest/rsc-1985-c-c-46.html 11 12

Peter Allatt, Bioethicist 2 MAiD Overview 5/19/2020 L

Shortening the 10 Day Reflection Period ESSONS LEARNED MAiD Process Acceptable criteria Death Patient at risk of • Phone OCC MD/NP • Report MAiD • Submit docs Criminal Code, RSC 1985, c C-46. s241.2 (3) http://www.canlii.org/en/ca/laws/stat/rsc-1985-c-c-46/latest/rsc-1985-c-c-46.html Unacceptable criteria1 Misinterpretation/Miscalculation • Review material OCC #1 • Contact family Suffering Pressure from the patient and/or their family members • Authorise OCC #2 release Logistics/Resources/Scheduling body

13 OCC = Office of the Chief Coroner 14 1. Roxanne Halko, Team Lead (MAiD), Office of the Chief Coroner for .

MAiD Request W HAT HAS BEEN CLARIFIED

MAID is not a palliative care issue;1,2 it is a health care issue. Not a failure of palliative care1

March 2018 JANUARY 2020 MAID is not a geriatrics issue; it is a health care issue. Not a failure of geriatric care

MAID is not a psychiatric issue; it is a health care issue. WHAT HAS BEEN CLARIFIED Not a failure of psychiatry What a MAiD Request is about; Medical Certificate of Death

It is a complex personal wish reflecting patient values.1

1. Al-Awamer, A. Physician-assisted suicide is not a failure of palliative care. Canadian Family Physician. December 2015, vol. 61 no. 12: 1039-40. http://www.cfp.ca/content/61/12/1039.full 2. Canadian Society of Palliative Care Physicians states “Palliative care does not include physician-hastened death. 15 “http://www.cspcp.ca/wp-content/uploads/2015/10/CSPCP-Key-Messages-FINAL.pdf

1 I W

MPACT ON Medical Certificate of Death HAT HAS BEEN CLARIFIED Prior to May 10, 2017 • Medical Certificate of Death H

EALTHCARE completed by coroner • Cause of Death: Combined drug toxicity • Manner of Death: Suicide

As of May 10, 2017 • Medical Certificate of Death completed by MAiD provider • Cause of Death: The illness, disease or disability leading to the request for MAiD (this condition will be selected as the cause of death for vital statistics) • Manner of Death: Natural • No reference to MAiD or drugs administered for the purpose of MAiD

1. Downer J. Sunday Edition. CBC 17 18 2. Buchman, S. Why I decided to provide assistance in dying: it is truly patient centred care. BMJ 2019;364;1412. doi10.1136/bmj.1412 Roxanne Halko, Team Lead (MAiD), Office of the Chief Coroner for Ontario.

Peter Allatt, Bioethicist 3 MAiD Overview 5/19/2020

This dying is: E THICAL

Patient Family P RINCIPLES

Way too slowPatient WayFamily too fast EFFECTIVE REFERRAL POLICY Conscientious objection respected but…

READY to die NOT ready for death

19 20 E E Effective Referral - CPSO FFECTIVE REFERRAL Conscientious Objection Conscientious Practice FFECTIVE When a health care The action that comes of Taking positive action to ensure the patient R

professional (HCP) respecting one’s own EFERRAL is connected to a refuses to partake in moral beliefs while at the a legal practice, P

same time respecting the P OLICY

OLICY Non-objecting which falls within their moral beliefs of others.1 scope of practice and professional competence on the basis of a deeply Available and held moral or ethical belief the action or inaction is wrong. Accessible • Physician, other health-care professional,

“… nothing in the declaration of invalidity which we propose to issue or agency. would compel physicians to provide assistance in dying.”1 CPSO. Policy Statement #2-15 Professional Obligations and Human Rights. March 2015. 21 22 1. Carter v Canada (Attorney General) 2015 SCC 5 https://www.cpso.on.ca/Physicians/Policies-Guidance/Policies/Professional-Obligations-and-Human-Rights

Challenges to CPSO Policies E Challenges to CPSO Policies cont. E FFECTIVE REFERRAL FFECTIVE REFERRAL CMDS and others Court of Appeal For Ontario Challenged CPSO policies Christian Medical and Dental Society of Canada v. College of Policy #4-16 Medical Assistance in Dying1 Physicians and Surgeons of Ontario, 2019 ONCA 393 Policy #2-15 Professional Obligations and Human Rights2 May 15, 2019 P P OLICY OLICY Ontario Superior Court of Justice, Divisional Court Appeal dismissed CMDS v CPSO 2018 ONSC 579 3 judges in agreement Jan 31, 2018 An effective referral does not guarantee a Unanimous decision patient will receive a treatment, or signal that Applications dismissed the objecting physician endorses or supports 4 the treatment. It ensures access to care and “Ordinarily, where a conflict arises between in their entirety 3 demonstrates respect for patient autonomy. a physician’s interest and a patient’s interest, the interest of the patient prevails.” 1. CPSO Policy #4-16 Medical Assistance in Dying. http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-in-Dying 2. CPSO Policy #2-15 Professional Obligations and Human Rights. http://www.cpso.on.ca/Policies-Publications/Policy/Professional-Obligations-and-Human-Rights 3. FACT SHEET: Ensuring Access to Care: Effective Referral. Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393 [187] http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/MAiD-Effective-Referral-FactSheet.pdf 23 (CanLII), , retrieved on 2019-10-02 24 4. CMDS v CPSO 2018 ONSC 579 https://www.canlii.org/en/on/onscdc/doc/2018/2018onsc579/2018onsc579.pdf

Peter Allatt, Bioethicist 4 MAiD Overview 5/19/2020

WHAT REMAINS UNCERTAIN VOLUNTARINESS #1 Best Practice??? Coercion v Coercion

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Voluntary – Criminal Code W Voluntary – CPSO Policy W HAT REMAINS UNCERTAIN HAT REMAINS UNCERTAIN Having MAiD Not Having MAiD Having MAiD Not Having MAiD (d) they have made a … voluntary and not voluntary request for made as a result of medical assistance in external pressure or dying that, in particular, coercion. was not made as a result -V -V 1 OLUNTARINESS OLUNTARINESS of external pressure. … has been made freely, without undue influence from family members, healthcare providers, or others.

1. Criminal Code (R.S.C., 1985, c. C-46)CCC 241.2 (1) (d) https://laws-lois.justice.gc.ca/eng/acts/C-46/page-52.html#h-79 CPSO. Policy Statement: Medical Assistance in Dying. 27 Https://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/medical-assistance-in-dying.pdf?ext=.pdf 28

Kay & Ernie Sievewright Shirley & George Brickenden W HAT REMAINS UNCERTAIN 55 yrs. Marriage 73 yrs. Marriage

Home

Duncan, B.C. , ON -V Jan 11, 2017; Jan. 15, 2017 March 27, 2018 Francois Boucher & Francine Messier Others OLUNTARINESS

50 yrs. Marriage VOLUNTARINESS #2 Couples Wanting MAiD Together

Hospital

Laval, QC 29 30 Oct. 31, 2019

Peter Allatt, Bioethicist 5 MAiD Overview 5/19/2020

Who should raise the issue? MA I “Is there D

any way CRITERIA we can WTHD speed“This this is

Dr. Matt Kutcher awful.up?” I : C “This is no “I don’t think MAiD should be something that want out.” LINICAL quality of we whisper about or something that we hide life.” anymore. I think the more we speak about it

and normalize it, the better.” MD/NP U NCERTAINTIES

“Your Patient WHO SHOULD RAISE MAID? treatment options are …” Consent Process

Canadian Medical Association. Medical Assistance in Dying. https://www.cma.ca/medical-assistance-dying 31 Is there a duty to inform? 32

Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data

Statistics as of April 30, 2020:

• Total number of cases completed in Ontario: 5,066 • Sex: – Female: 50% • Type: – Male: 50% – Clinician-administered: 5,064 – Patient-administered: 2 • Age: – Average Age: 75 – Youngest: 22 • Setting of death: – Oldest: 106 – Hospital: 46% – Private Residence: 44% • Underlying conditions: ONTARIO STATISTICS: DR. DIRK DUYER, CHIEF CORONER – LTC Facility/Nursing Home: 6% – Cancer-Related: 63% – Retirement Home/Seniors Residence: 4% – Circulatory/Respiratory: 18% June 7, 2016 → – Neurodegenerative: 11% – Other: 8% • Number of Unique MAiD Providers: – Clinicians: 528 – Physicians: 490 • Total # of cases with organ donation: 42 Cumulative Statistics – Nurse Practitioners: 38 – Hospitals: 137

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Office of the Chief Coroner/Ontario Forensic Pathology Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data Service MAiD Data

County MAiD Cases Manitoulin 6 Algoma County 44 Middlesex County 311 Statistics as of April 30, 2019: Brant County 37 Muskoka District Municipality 48 55 Niagara Regional Municipality 140 • Clinician Specialty: Chatham - Kent Division 48 109 – Family Medicine: 62% Cochrane District 35 Northumberland County 77 – Internal Medicine: 9% 20 Division 420 – General Practitioner: 9% Durham Regional Municipality 134 Oxford County 55 – Emergency/Critical Care Medicine: 7% 44 24 – Anesthesiology: 7% Essex County 121 Peel Regional Municipality 291 – Surgery: 2% 137 Perth County 73 – Oncology: 2% Division 33 115 – Other: 2% 69 Prescott & Russell United Counties 55 Haldimand-Norfolk Regional Municipality 41 Prince Edward Division 18 14 19 • Reflection Period: Halton Regional Municipality 230 20 – % Cases with < 10 clear days: 25% Hamilton Division 160 213 – Rationale: 75 Stormont, Dundas & Glengarry United Counties 56 – Imminent Loss of Capacity: 14% Huron County 29 < 5 – Imminent Death: 3% Kawartha Lakes Division 55 78 – Both: 8% 35 22 27 Toronto Division 905 65 Waterloo Regional Municipality 102 Leeds & Grenville United Counties 107 Wellington County 93 Lennox & Addington 23 York Regional Municipality 168

Peter Allatt, Bioethicist 6 MAiD Overview 5/19/2020

Office of the Chief Coroner/Ontario Forensic Pathology Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data Service MAiD Data

Statistics as of March 31, 2020: Statistics as of March 31, 2019:

• Total number of cases completed in Ontario: 4,888 • Sex: • Clinician Specialty: – Female: 50% – Family Medicine: 61% • Type: – Male: 50% – Internal Medicine: 10% – Clinician-administered: 4,886 – General Practitioner: 9% – Patient-administered: 2 • Age: – Emergency/Critical Care Medicine: 7% – Average Age: 75 – Anesthesiology: 7% – Youngest: 22 – Surgery: 2% • Setting of death: – Oldest: 106 – Oncology: 2% – Hospital: 47% – Other: 2% – Private Residence: 43% • Underlying conditions: – LTC Facility/Nursing Home: 6% – Cancer-Related: 63% – Retirement Home/Seniors Residence: 4% – Circulatory/Respiratory: 17% • Reflection Period: – Neurodegenerative: 11% – % Cases with < 10 clear days: 24% – Other: 9% – Rationale: • Number of Unique MAiD Providers: – Imminent Loss of Capacity: 14% – Clinicians: 519 • Total # of cases with organ donation: 41 – Imminent Death: 3% – Physicians: 481 – Both: 7% – Nurse Practitioners: 38 – Hospitals: 137

Questions Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data Part 1 County MAiD Cases 6 Algoma County 41 Middlesex County 298 Brant County 37 Muskoka District Municipality 48 Bruce County 52 Niagara Regional Municipality 133 Chatham - Kent Division 47 Nipissing District 107 Cochrane District 32 Northumberland County 74 Dufferin County 18 Ottawa Division 410 Durham Regional Municipality 130 Oxford County 53 Elgin County 43 Parry Sound District 24 Essex County 114 Peel Regional Municipality 277 Frontenac County 134 Perth County 70 Greater Sudbury Division 30 Peterborough County 112 Grey County 65 Prescott & Russell United Counties 53 Haldimand-Norfolk Regional Municipality 40 Prince Edward Division 17 Haliburton County 12 Rainy River District 17 Part 1 Halton Regional Municipality 218 Renfrew County 20 Hamilton Division 158 Simcoe County 202 Hastings County 73 Stormont, Dundas & Glengarry United Counties 56 Huron County 29 Sudbury District < 5 Kawartha Lakes Division 53 Thunder Bay District 76 Kenora District 34 Timiskaming District 21 Lambton County 27 Toronto Division 881 Lanark County 63 Waterloo Regional Municipality 97 Leeds & Grenville United Counties 104 Wellington County 89 Lennox & Addington 27 York Regional Municipality 163 Comments 40

Peter Allatt, Bioethicist 7