Dr. Jenny Ingram, Seniors Physician Lead, Central East LHIN NP Deb Daly, Regional Clinical Lead, GAIN, Seniors Care Network May 11, 2017

Transcription

1 Dr. Jenny Ingram, Seniors Physician Lead, Central East LHIN NP Deb Daly, Regional Clinical Lead, GAIN, Seniors Care Network May 11, 2017

2 Faculty: Dr K Jennifer Ingram Relationships with commercial interests: Grants/Research Support: 1. CIHR funded Research Primary Care Memory Clinics 2. Industry funded Eli Lilly Astra Zeneca Biogen Merck Roche Funding to Kawartha Regional Memory Clinic 3. Consulting Fees: Portfolio Site Roche Eli Lilly. 4. Other: CE LHIN Seniors Lead and SCN Board Chair and Capacity Assessor

3 Faculty: NP Debbie Daly Relationships with commercial interests: None

4 This Presentation Will not contain any proprietary information Will not refer to any pharmaceutical agent/company and Will address only known and scientifically proven facts available publically

5 At the conclusion of this presentation, participants will: Review the definition & criteria for Medical Assistance in Dying (MAiD) Identify probable circumstances precluding MAiD in frail senior care Articulate possible clinical responses for those who are deemed ineligible Consider communication techniques for discussion of this topic

6 Five Core SGS programs Geriatric Assessment & Intervention Network (GAIN) 12 interprofessional teams across the LHIN Geriatric Emergency Management (GEM) Behavioural Supports Ontario (BSO) Nurse Practitioners Supporting Teams Averting Transfers (NPSTAT) Senior Friendly Care

7 Approximately 180 funded health care providers and other non-funded colleagues collaborate to deliver specialized services to the most vulnerable older adults in the region More than 27,000 direct encounters across four clinical programs in 2014/15

8 Administration by a physician or nurse practitioner of a substance to a person, at their request, that causes their death ( voluntary euthanasia ) or Prescribing or providing (by a physician or nurse practitioner) of a substance to a person, at their request, so that they may selfadminister the substance and in doing so cause their own death ( assisted suicide ). CPSO, June 2016

9 Three Stages in Medical Assistance in Dying: 1. Determining eligibility 2. Ensuring safeguards are met 3. Providing Medical Assistance in Dying, whether it is provided by the NP or physician, or self-administered by the client

10 1. Eligibility for health services funded by the federal government, or a province or territory Generally, visitors to Canada are not eligible for medical assistance in dying. 2. At least 18 years old and capable of making decisions with respect to their health 3. Have a grievous and irremediable medical condition (includes illness, disease or disability) 4. Voluntarily request medical assistance in dying (specifically, not as a result of external pressure) 5. Gives informed consent to receive medical assistance in dying after they were informed of treatments available to relieve their suffering, including palliative care. CNO, May 2017

11 Patients must be mentally competent and capable of making decisions at the time that the service is provided. The physician or nurse practitioner will ask them to confirm their choice right before administering medical assistance in dying. Patients are able to withdraw consent at any time.

12 You are considered capable of consenting to a treatment if you are able to: understand the information that is needed to make a decision about your treatment Appreciate the consequences of the decision (and the consequences of the lack of a decision)

13 People with a mental illness are eligible for Medical Assistance in Dying as long as they meet all of the listed conditions. However, they are not eligible for this service if: suffering only from a mental illness; death is not reasonably foreseeable when considering all the circumstances of the medical condition; or a mental illness reduces ability to make medical decisions CPSO, June 2016

14 The health care provider proposing treatment always assesses the person s capacity to provide consent. Assent is considered to be evidence of consent in health care practice (for most medical situations bloodwork, vital signs, participating in assessments). People can be found competent to make one health care decision (what to eat and drink), but not for another (to refuse surgery). People can also be capable to consent one day but not the next. HCCA, 1996

15 Can I add a clause in my Advance Directive that instructs my family and care team to provide Medical Assistance in Dying if I become incapable? Can my Substitute Decision Maker instruct my MD/NP to provide MAiD on my behalf, knowing those were my last capable wishes?

16 Patient must meet all of the following conditions: they have a serious and incurable illness, disease or disability they are in an advanced state of irreversible decline in capability that illness, disease, disability or state of decline causes them enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable their natural death is 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. CNO, 2017; CPSO 2017

17 The patient does not need to have a fatal or terminal condition Must be a real possibility of death evidenced by the patient s irreversible decline within a period of time that is foreseeable in the not too distant future The nature of the illness causing the intolerable and enduring suffering and any other medical conditions or health-related factors such as age and/or frailty are to be considered in assessing trajectory towards death Government of Canada, Retrieved May 9, 2017

18 What happens if the assessing MD/NP finds that I am not eligible for Medical Assistance in Dying?

19 1. Written Request 2. Independent Witnesses 3. Second Opinion

20 The person must make a written request for MAiD Request must be signed and dated by the client after they have been informed by MD/NP that they have a grievous and irremediable medical condition. If person is unable to physically sign, another individual may do so in the requesting person s presence under their express direction.

21 2 people, over age 18 who Understand the nature of Medical Assistance in Dying Both must witness the person requesting MAiD sign and date the request Neither witness may: Knowingly benefit from person s death Own/operate facility where person is receiving treatment or lives Be directly involved in providing health care services or personal care to the person

22 A second MD/NP must also provide a written opinion confirming that patient is eligible according to all listed conditions. Both MD/NPs must be independent: No mentoring or supervisory relationship between providers Not a beneficiary of the person s will Unaware of any financial or material benefit resulting from the person s death Not connected to the person in any way that would affect objectivity.

23 Patient must wait a period of at least 10 days between signing their request and the provision of service. An exception may be made if: death is fast approaching person might soon lose capacity to provide informed consent Government of Canada, Retrieved May 9, 2017

24 The single biggest problem with communication is the illusion that it has taken place George Bernard Shaw ( )

25 Geriatric specialists distinguish ourselves in our ability see the whole picture - to comprehensively evaluate as well as communicate with patients and families Each geriatric team member needs comfort in the role of providing support Should have the same vantage point for this person s specific situation. Team works together to avoid creating confusion for the patient

26 MAiD unlikely to be a common occurrence We need to continue to practice so that we are comfortable with discussing end of life care Communication can t be delegated completely to the family we need to participate and provide guidance and information

27 Assessing and interpreting frailty: Enables us to adequately identify trajectory of change Provides ability to contextualize reserve and frailty and assist family in thinking it through. As people age, less and less reserve not wrong to do or not do something, just go into this with eyes open

28 Baby Boomers think of dying as Optional We all want to keep Control even when we can t. Our role is to help people understand what they can and can t control We want our chosen Substitute Decision Maker to understand and follow our wishes Systems of care are demanding written SDM/POA and in certain circumstances signed Advance Directives

29 Advance care directive Personal directives, Treatment directives Proxy directives A living will is not a binding legal document but another form of advance directive, which sets out an individual s wishes in relation to a terminal illness

30 Advanced Directives (AD) help guide care - every specialized geriatric service needs to review with the capable patient once, and again if a major change in status occurs. Ensure Substitute Decision Maker (SDM) is aware of patient s wishes When reviewing, If patient incapable of health care direction, review directive with SDM

31 Healthcare consent act (HCCA) identifies hierarchy of SDM Every Patient in Ontario automatically has a person who will have legal authority to act as his/her SDM if they become incapable through HCCA Hierarchy: 1. Guardian of the Person with authority for Health Decisions 2. Attorney for personal care with authority for Health Decisions (POA) 3. Representative appointed by the Consent and Capacity Board 4. Spouse or partner 5. Child or Parent or CAS (person with right of custody 6. Parent with right of access 7. Brother or sister 8. Any other relative 9. Office of the Public Guardian and Trustee HCCA, 1996

32 HCCA allows non-poa to make decisions even when POA exists you can share info with offspring if husband is POA and does not attend visit Previously stated wishes and best interest apply as rules for all Only necessary to invoke POA if there is family discord

33 Think through the care contextualize treatment Identify What treatment is being proposed What outcome of intervention can be expected What outcomes if the intervention is not accepted Expect discussion, debate and explanation of information and decisions especially if non congruent with rest of team or with rest of family

34 Encourage patients to talk to their health care provider, family, friends or other caregivers about end-of-life care options/wishes. Options may include: do not resuscitate orders understand stigma, misunderstandings re this decision refusal or withdrawal of treatment refusal of food and drink palliative sedation to ensure comfort medical assistance in dying

35 1. Discussion is always patient centered & comprehensive 2. Explain the issues (comprehensive picture) 3. Detail the reversible or treatable options 4. Identify the results of each, with treatment and without treatment 5. Create an understanding of where patient lies in spectrum of care options 6. Try to instill cooperation in communication 7. If cooperation then try to instill a sense of joy/honor/benefit

36 Completely capable 87F referred; feeling unwell X 3 months Staying in Bed +++/ Short of Breath with walking Using electo-magnetic fields, Coconut oil, Vitamin D (suggested by son, a Chiropracter) Awakening in night with sudden onset short of breath (PND) In ED given Lasix Coumadin and antihypertensive nonadherent at home Echo 30% ejection fraction; but no cardiologist Family heavily committed to Naturopathic care (not all family, and some family upset over this )

37 Patient unable to understand why the medications were previously recommended When existing Echo cardiogram read and explained willing to go through with usual medical care (pericardial effusion Ejection Fraction 30% - Intraventricular Clot ) Advance planning often changes in the face of serious illness Previous expressed wishes do not have to bind patients to a decision.

38 If the adequately informed patient and family ultimately decide for no treatment, and ask for MAiD, go back to the basics Reasonably foreseeable death Capacity On both counts, many pts may not have the requisite skills necessary