Medical Aid in Dying A Year of Change

Transcription

1 Medical Aid in Dying A Year of Change Howard Lim, MD, PhD, FRCPC Chair, Gastrointestinal Tumour Group Program Director, Medical Oncology Residency Training Program Clinical Associate Professor, University of British Columbia Division of Medical Oncology, BC Cancer Agency

2 Disclosures Received honorariums from Roche, Lilly, Amgen, Leo and Bayer for consultant work Received travel support from Bayer I did my GI fellowship in Oregon

3 Background GI Oncologist did some of my training in Oregon I have no formal training in ethics Lots of changes in the last year good time to discuss things!

4 Why the interest? Aging population Fear of dying/lack of palliative care Increasing incidence and prevalence of chronic disease Increase in social media Control

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7 Gillian Bennett Dr. Donald Low Brittany Maynard

8 Does everyone know what they are talking about? Physicians and patients inaccurately describe what is end of life care vs. euthanasia Some people felt that administrating pain meds was euthanasia Some patient s families will report that they adequate palliative care but that the patient still suffered Suffering very subjective

9 Definitions Medical aid in dying intentionally participating in the death of patient by either directly administrating a substance or providing a means through self administration. Euthanasia the act of administrating lethal medication in accordance to the wishes of the person Assisted Suicide the act of suicide with the assistance of another

10 What defines a good death? Highly personal Full range of the spectrum Passing away peacefully at home with family Full code chemotherapy Subjective Can adequately palliate symptoms but still suffer?

11 Is there a solution? Are people ready to plan their death? Surveys indicate families wish their care providers spoke to them about end of life issues earlier Yet attempting to address this is time consuming and difficult if patients are not ready to address this. Public concerns about loss of autonomy and dignity near the end of life

12 Current State On February 6, 2015, the Supreme Court of Canada (SCC) in Carter v. Canada struck down the provisions in the Criminal Code prohibiting physicianassisted dying (also known as medical assistance in dying). On June 6, 2016 medical assistance in dying (MAiD) became legal in Canada.

13 Current State On June 17, 2016 legislation on medical assistance in dying (Bill C-14) received royal assent, making Bill C-14 an Act of Parliament and part of Canadian law. The Parliament has amended the Criminal Code, RSC 1985, c.c-46 to allow MAiD under certain limited circumstances as outlined in Bill C-14.

14 Eligibility criteria under Bill C-14: A. They are eligible for health services funded by a government in Canada; B. They are at least 18 years of age and capable of making decisions with respect to their health;

15 Eligibility They have a grievous and irremediable medical condition; a person has a grievous and irremediable medical condition only if they meet all of the following criteria:

16 Criteria I. They have a serious and incurable illness, disease or disability; II. They are in an advanced state of irreversible decline in capability;

17 Criteria III. That illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and

18 Criteria IV. Their natural death has become 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.

19 Criteria D. They have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and E. They give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.

20 Process The process respecting MAiD involves the opinion of two independent medical assessors (MAs), one of whom shall also be the prescriber/administrator of the lethal substances. Only a physician or nurse practitioner may be a MA.

21 Process Must have the skill set to render a diagnosis and prognosis of the patient s condition Skill set to provide MAID Provide all information for all options to the patient so that they can make an informed decision

22 Process Assessors should be independent of each other Should assess capacity to make decision if this changes can not proceed with MAiD Can not be done by substitute decision maker or advanced directive Must be requested in writing with two witnesses who are not involved or related to the patient

23 Physicians must inform the patient requesting MAiD of the following and the information must be included in the patient s medical record with a copy provided to the patient: a.the patient s diagnosis and prognosis b.feasible alternatives (including comfort care, palliative care and pain control) c. option to rescind the request for MAiD at any time d. risk of taking the prescribed substances

24 Process A secondary function of the MAiD office is to oversee compliance of documentation regulations. This involves: Ensuring that all aspects of the MAiD request are appropriately documented and proper records are maintained. Required Government reporting for the purpose of permitting and monitoring of MAiD

25 Data so far: CBC News called all 13 provinces and territories in an effort to find out Oct 11: Ontario's coroner recorded 87 cases of medically assisted death. British Columbia reported 66. Alberta's provincial health authority said there were 23 cases. Manitoba had 12 recorded cases.

26 Cases so far: The Yukon, New Brunswick and Nova Scotia all declined to provide a precise number, citing privacy concerns. Nunavut, Northwest Territories, Prince Edward Island, and Newfoundland and Labrador all said they had no reported deaths during that two-month period. Saskatchewan said there were fewer than five cases.

27 Other points Insurance Canadian Life and Health Insurance Association will pay out policy and forgo waiting 2 years for suicide cases

28 Other points Funerals Alberta/NWT Bishops insturcted priests to refuse funerals for people who have chosen MAID MAID is a grave sin BC Bishops have been softer on this stance

29 Discussion What if I object? I work in a rural area what are my options for support? Assessment for capacity and support for assessments for competence when does the assessment expire? Ensuring patient s meet criteria Assessing coercion

30 Final thoughts Media attention to MAID can help facilitate end of life discussions Need more resources for end of life care/education both for professionals, patients and families The role of MAID will always be controversial HCP should be allowed to treat patients according to their conscience If conducted in a transparent manner, MAID may be a reasonable option for certain patients as part of a end of life care plan. MAID and palliative care are two separate issues and should not be lumped together

31 Information CMA online course PHSA Risk Management office POD MAiD resources Local Health Authority BC College Website pdf document outlining MAiD