Understanding Medical Assistance in Dying (MAID): The Experience

Halton Age Friendly Network November 12, 2020 Dianne Godkin, PhD Senior Ethicist,

Investigator, Institute for Better Health Past-President, Canadian Bioethics Society Member, Canadian Association of MAID Assessors and Providers Member, University of Joint Centre for Bioethics Adjunct Lecturer, Faculty of Nursing,

2 My Role

• Advocated for the establishment of a working group to determine Trillium Health Partner’s (THP) approach to medical assistance in dying • Co-chaired working group • Also a member of University of Toronto Joint Centre for Bioethics Task Force on MAID

Credit Valley Hospital Hospital Queensway Health Centre 3 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto My Role (cont.)

• AID Coordinator at THP from June 2016 to June 2017 – responded to 65 requests & direct oversight of 35 provisions • Continue as Co-chair of AID Oversight Committee • Regularly meet with AID Coordinator(s) • Consult on complex cases

Credit Valley Hospital Queensway Health Centre 4 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Outline

• To provide a timeline of important events related to medical assistance in dying (MAID) • To highlight key aspects of legislation that governs MAID including eligibility requirements • To reflect on MAID experience in Ontario • To discuss other challenges and future considerations

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 5 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Poll Question #1

6 Time Line

7 In the Beginning…

• In 1993, in a 5-4 split decision, the Supreme Court of Canada (SCC) ruled that it was not an individual’s right, but rather the government's right to decide the circumstances of one’s death. • The ruling was based in part on lack of legal precedence/experience in other countries, public opinion at the time, and the nature of the Sue Rodriguez application.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 8 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto In the Intervening Years…

• Multiple private member’s bills and court cases • Increasing public awareness and calls for change

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 9 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto SCC Decision…2015

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 10 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Post Carter…

• February 6, 2016 – One year suspension to allow legislation to be drafted and approved. • February 29, 2016 – First court approval of exemption for physician assisted death (HS (Re), 2016 ABQB 121) in Alberta received and enacted. • March 17, 2016 – First court approval of exemption for physician assisted death granted in Ontario. • June 17, 2016 – Bill C-14 receives royal assent (court approval process no longer required) • May 9, 2017 – Bill 84 enacted in Ontario.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 11 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 and Bill 84

12 Bill C-14 Overview

• Recognize individual choice of a medically assisted death for adults who are suffering intolerably and for whom death is reasonably foreseeable • Affirm the inherent and equal value of every person’s life • Avoid encouraging negative perceptions of the quality of life of persons who are elderly, ill or disabled • Protect vulnerable people from being encouraged to die in moments of weakness • Reaffirm society’s goals with regard to preventing suicide • Encourage a consistent approach to medical assistance in dying across Canada

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 13 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 – Medical Assistance in Dying

• There are 2 types of medical assistance in dying available to Canadians. • They include where a physician or nurse practitioner: – directly administers a substance that causes death, such as an injection of a drug (commonly called voluntary euthanasia) – gives or prescribes a drug that is self-administered to cause death (commonly known as medically-assisted suicide)

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 14 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 – Who?

• Who can provide assistance… – physicians – nurse practitioners (in provinces where this is allowed) • Who can help in providing assistance in dying... – pharmacists – health care providers who help physicians and nurse practitioners – family members or other people that patient asks to help

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 15 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 Eligibility Criteria

• Eligible, for health services funded by a government in Canada • 18 years of age • Capable of making decision • Voluntary request • Grievous and irremediable medical condition • Informed consent

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 16 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 Grievous and Irremediable

• Serious and incurable illness, disease, or disability • Advanced state of irreversible decline in capability • Patient enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and • Patient’s natural death reasonably foreseeable, 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

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 17 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 Safeguards

• Medical or nurse practitioner ensures person meets all criteria • Request for assistance in dying that is written, signed, dated and witnessed by two independent persons • Person informed that they may withdraw request at any time • Second independent medical or nurse practitioner confirms person meets all criteria • Waiting period of 10 “clear” days between request and provision of assistance in dying • Immediately prior, person given opportunity to withdraw; ensures express consent

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 18 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 Protections

• No adverse legal consequences for the families of persons who choose medical assistance in dying including the loss of eligibility for benefits

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 19 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Council of Canadian Academies Reports

• Bill C-14 mandated a review of medical assistance in dying in three complex scenarios: – mature minors – advance requests – mental disorder is the sole underlying medical condition • Reports were released in December 2018 - described as providing a summary of the current state of knowledge in each area; they did not make any specific recommendations

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 20 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill 84

The Act amends six pieces of legislation including: • Excellent Care For All Act, 2010 – To protect rights and benefits (e.g., life insurance) – To provide civil immunity to care providers including institutions, physicians, nurse practitioners and persons assisting them in the lawful provision of MAID; and – To require the Minister of Health and Long-Term Care to establish a Care Co-ordination Service • Workplace Safety and Insurance Act, 1997 – To clarify that a person who received MAID is deemed to have died as a result of their underlying injury or illness

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 21 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill 84 (cont.)

• Freedom of Information and Protection of Privacy Act and Municipal Freedom of Information and Protection Privacy Act – To prevent identifying information about individuals and facilities willing to provide MAID, from disclosure under access to information requests • Coroners Act – To require that the coroner be notified of all MAID deaths and allow the coroner to determine whether to investigate the death

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 22 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill 84 (cont.)

• Vital Statistics Act – To make technical amendments regarding the completion of Medical Certificates of Death consistent with the Coroners Act amendments

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 23 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Court Challenges – Effective Referral

January 2018 - Divisional Court of Ontario (the "Court") released its decision in The Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2018 ONSC 579. Conclusion - The Court dismissed the application, concluding that the infringement of religious freedom was demonstrably justified. This decision was subsequently appealed. May 2019 – The Court of Appeal for Ontario reaffirmed a lower court’s conclusion that it was a reasonable limit on the religious freedom of doctors to require them to connect their patients with willing providers of medical assistance-in-dying (MAID) and other contentious health services.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 24 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Court Challenges – Reasonably Foreseeable Criteria

• June 2016 - British Columbia Supreme Court • July 2017 - Ontario Superior Court of Justice • September 2019 – Quebec Superior Court

• This criteria was struck down and a deadline of December 18 for changes to be made is in place.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 25 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-7 – Proposed Changes

• As per the Quebec ruling, “natural death is reasonably foreseeable” is no longer a required criteria. • Persons whose sole underlying medical condition is a mental illness would not be eligible for MAID. • All practitioners who assess MAID eligibility must submit information to federal government. • Two streams with different safeguards have been proposed – those whose natural death is reasonably foreseeable and those for whom it is not

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 26 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Bill C-14 Safeguards Bill C-7 Proposed Safeguards (current) Death is Reasonably Death is Not Reasonably Foreseeable Foreseeable --10 day reflection period --no reflection period --90 day reflection period Written request: Written request: • requires 2 independent • requires 1 independent witness witnesses • healthcare workers can act as witness • healthcare workers cannot act as witness Assessors: MD or NP Assessors: MD or NP Assessors: MD or NP with expertise in the condition causing the person’s suffering Consent: Waiver of Consent: Consent: --required immediately --not required immediately --required immediately before MAID is provided before MAID is provided if a before MAID is provided number of conditions met

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 27 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Poll Question # 2

28 Cost Estimates

• Under Bill C-14 (current law), the projected gross reduction in health care costs for 2021 is estimated to be $109.2 million while the cost of administering MAID is estimated at $22.3 million. The difference between the two represents a net reduction in cost of $86.9 million per year. • Additional cost savings if Bill C-7 is enacted are estimated to be $62.0 million per year for a total of $149 million per year • This would account for approximately .08% of total provincial health care budget. (Office of the Parliamentary Budget Officer, October 2020)

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Access to MAID

30 Within Central Region

• Available in hospital setting to patients with an affiliation to the following hospitals – Trillium Health Partners – Halton Healthcare Services – William Osler Health Centre • Available in the community setting through coordination by Community and Home Care (formerly CCAC)

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 31 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Provincial Care Coordination Service

• As of May 31, 2017 – Patients and caregivers looking for more information or support with MAID can call the care coordination service to request to be connected to a doctor or nurse practitioner who can provide medical assistance in dying services, such as eligibility assessments. – Doctors or nurse practitioners who are unable or unwilling to provide MAID can also contact the care coordination service to refer their patients to doctors or nurse practitioners who can provide these services.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 32 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Professional College Expectations

• Physicians – To inform patient if not willing to assist – To make an effective referral • Nurses – “conscientious objection must not be directly conveyed to the client and no personal moral judgments about the beliefs, lifestyle, identity or characteristics of the client should be expressed” • Pharmacists – To make an effective referral

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 33 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Other Resources

• Centre for Effective Practice (TheWell™) • Dying with Dignity – Volunteers to witness written requests of patients – Personal support program – Bereavement programs • Ministry of Health and Long Term Care… – Patient Information http://health.gov.on.ca/en/pro/programs/maid/docs/maid.pdf – Healthcare Provider Information http://health.gov.on.ca/en/pro/programs/maid/

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 34 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Documentation Forms

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 35 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Organ and Tissue Donation after MAID

• Trillium Gift of Life Network is notified of all possible MAID cases after the patient has been found eligible by at least one physician or nurse practitioner, if the patient is <80 years of age. • Express consent is sought from the donor. • Decision for MAID must precede organ donation conversation.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 36 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Ontario Statistics

37 Ontario Statistics (as of September 30, 2020)

• 6059 provisions • 2 oral; 6057 IV administration • 47% in home; 43% hospital; 10% long term care/retirement home • 63% cancer diagnosis; 17% circulatory/respiratory; 11% neurodegenerative; 9% other • 50% female; 50% male • Age range from 20 to 106, average age of 75

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Ontario Statistics (cont.)

• 144 hospitals • Number of Clinicians: – 523 physicians (63% family physicians) – 43 nurse practitioners • 46 organ donations • Reflection period waived for 25% (imminent loss of capacity or imminent death)

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 39 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Ontario – Number of Cases / Quarter

700 604 600 570 557 519 496 500 408 411 406 400 358 368 322 300 233 249

200 180 181 108 100 79

0 0

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 40 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto What I have learned through my involvement in MAID… Case Scenario

• Mr. B was an elderly man with metastatic cancer. • After several courses of chemotherapy he was weak and emaciated. • His body hurt all over. • His world had shrunk to a hospital bed in his condo.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 42 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Case Scenario (cont.)

• When his palliative care doctor arrived for a home visit, Mr. B’s first question was: “When is this suffering going to end?” • His next question was: “Can you help me to die?” • His palliative care doctor initiated the eligibility assessment process.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 43 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Case Scenario (cont.)

• When Mr. B was informed that he was eligible, he was elated; his shoulders relaxed and he smiled widely. • A date was set for his admission to hospital to receive medical assistance in dying. • When he arrived at the hospital, he looked quite uncomfortable. • He stated that he had not taken any pain medication because he wanted to ensure that he was alert and able to consent.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 44 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Observation #1

• The positive impact of finding a patient eligible • The benefit of providing patients with an opportunity to be assessed for eligibility for assistance in dying in contexts where the patient may not be ready to proceed immediately (concept of "in my back pocket").

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 45 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Being Found Eligible

• Relief • Reduction in Anxiety & Fear • Happiness • Calm • Peaceful • Joy

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 46 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Observation #2

• The speed at which assistance in dying has been incorporated into practice at THP.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 47 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Integration into Practice

• Uptake was quick and steady • Initial concerns dissipated from some groups

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 48 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Observation #3

• The unintended and negative consequences of requiring a 10 day waiting period between the day of the written request and the day of provision.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 49 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto 10 Day Waiting Period

• Worry about loss of capacity • Refusal of pain medication • Cruel punishment • Anger • Disappointment

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 50 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Observation #4

• The patient’s commitment to follow through with MAID, once found eligible and a date for provision has been set.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 51 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Unwavering Commitment

• In spite of family objections • Despite being asked multiple times • Actions taken to ensure capacity

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 52 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Observation #5

• The importance of hearing the patient's story for those involved in responding to patient requests for assistance in dying.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 53 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto The Patient’s Story

• Pharmacists/Pharmacy Technicians • Leadership Team • AID Oversight Committee

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 54 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Observation #6

• How quickly and peacefully death by medical assistance in dying unfolds.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 55 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Challenges and Future Considerations

56 Practice Concerns

• Variation from province to province (e.g., differences in interpretation of criteria, medications, billing, role of coroner) • Prevention of compassion fatigue and burnout • Appropriate medications for oral administration • Lack of funding – disproportionate burden on providing hospitals/providers

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 57 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Unsettled Issues

• Access for mature minors • Advance requests when a person doesn’t yet meet eligibility requirements for MAID • Access for patients whose sole underlying medical condition is a mental illness (likely a charter challenge if this restriction is approved as part of Bill C-7) • What counts as “reasonably foreseeable natural death” is likely to be a contentious issue if Bill C-7 is approved

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 58 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Poll Question # 3

59 What you need to know…

• You have a right to be assessed for eligibility for medical assistance in dying (make the request to a physician or nurse practitioner or contact the Ministry coordination service). • You have a right to request a second opinion if found ineligible by the first assessor. • You have a right to change your mind at any point in the process and withdraw your request.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 60 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Summary

• The number of requests/provisions are tracking toward the higher end of numbers that were expected based on other jurisdictions. • There has been a shift in attitudes towards assistance in dying by many physicians/staff who have directly encountered a patient request. • Patient requests predominantly coming from patients who are receiving excellent palliative care. • Meeting the demand will become increasingly difficult to support unless targeted resources are provided.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 61 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto Closing Thoughts

• It has been a privilege to accompany patients who have requested and/or received assistance in dying and their family members. • I am honoured to work alongside a wonderful group of compassionate healthcare providers. • We continue to learn how best to provide care in the context of intolerable suffering. • There remains more work to be done…

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 62 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto References/Resources

Appelbaum, P. S. (February 10, 2016). Physician-Assisted Death for Patients with Mental Disorders – Reasons for Concern. JAMA Psychiatry, E1-E2. Canadian Psychiatric Association Interim Response to Special Joint Committee (April 2016). Available at: http://www.cpa-apc.org/wp-content/uploads/2016-04-11-CPA- Letter-Minister-Wilson-Raybould-PAD.pdf Ferrier, C. (June 10, 2016). Advance Request for Euthanasia? Impact Ethics Blog. Available at: https://impactethics.ca/2016/06/10/advance-request-for-euthanasia/ Health Canada. (July 2020). First Annual Report on Medical Assistance in Dying. Available at: https://www.canada.ca/en/health-canada/services/medical-assistance- dying-annual-report-2019.html Hertogh, C. M., de Boer, M. E., Droes, R. . Eefsting, J. A. (2007). Would we rather lose our life than lose our self? Lessons from the Dutch debate on euthanasia for patients with dementia. American Journal of Bioethics, 7(4), 48-56.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 63 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto References/Resources

Kim, S. Y. H., De Vries, R. G., & Peteet, J. R. (February 10, 2016). Euthanasia and Assisted Suicide of Patients With Psychiatric Disorders in the Netherlands 2011 to 2014. JAMA Psychiatry, E1-E7. Menzel, P. T., & Steinbock, B. (2013) Advance Directives, Dementia, and Physician- Assisted Death. The Journal of Law Medicine & Ethics, 41(2) 484-500. Office of the Parliamentary Budget Officer. Cost Estimate for Bill C-7 “Medical Assistance in Dying” (October 20, 2020). Provincial Territorial Expert Advisory Group on Physician Assisted Dying. Final Report (November 30, 2015). Report of the Special Joint Committee on Physician-Assisted Dying (February 2016). Available at: http://www.parl.gc.ca/content/hoc/Committee/421/PDAM/Reports/ RP8120006/pdamrp01/pdamrp01-e.pdf Trachtenberg, A.J. & Manns, B. (2017). Cost analysis of medical assistance in dying in Canada. Canadian Medical Association Journal, 23(189), E101-E105.

Credit Valley Hospital Mississauga Hospital Queensway Health Centre 64 2200 Eglinton Avenue West, Mississauga 100 Queensway West, Mississauga 150 Sherway Drive, Toronto QUESTIONS/ COMMENTS

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