Understanding Medical Assistance in Dying (MAID): The Ontario Experience Halton Age Friendly Network November 12, 2020 Dianne Godkin, PhD Senior Ethicist, Trillium Health Partners Investigator, Institute for Better Health Past-President, Canadian Bioethics Society Member, Canadian Association of MAID Assessors and Providers Member, University of Toronto Joint Centre for Bioethics Adjunct Lecturer, Faculty of Nursing, University of Toronto 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 Mississauga 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 Mississauga 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