Guest post by Dr. Amita Dayal, a rural family and ER physician with a focus on end-of-life care.
She sits across from me, walker poised in front of her, bent over in pain and much thinner than I remember her being on our last visit. Her daughter watches her carefully as she speaks to me: “Doctor,” she says, “the oncologist says there is nothing else they can do for me. The treatments have all failed and are just making me sicker. My palliative care doctor is keeping me comfortable, but I saw my father die of cancer and I don’t want to lose control like that. I want dignity.”
On February 6, 2015, the longstanding federal prohibition on physician assistance in dying was unanimously overturned. In its place, the groundbreaking new law, Bill C-14 came into effect in Canada on June 17, 2016. Since that time, it has been legal for medical professionals to assist patients in dying, as long as they meet the criteria set out in Bill C-14. Medical Assistance in Dying, or MAiD, is carried out with the use of a medication which can be administered by a doctor or nurse practitioner (NP) directly, or prescribed for self-administration, if preferred.
Death by Numbers
A 2017 Health Canada Report revealed that 1,982 people accessed MAiD in Canada during the year following Bill C-14. Greater than 99% of the deaths were clinician-administered, and patients most commonly had diagnoses of cancer, or neurologic conditions such as amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS).
How to Access MAiD
MAiD is accessed through physicians and nurse practitioners. Family doctors, intensive care and palliative care physicians and/or nurse practitioners most commonly provide MAiD; however, a patient looking to know more about MAiD can ask any health professional for information. To start, great patient and family resources are available through the Ministry of Health and Dying with Dignity.
Some physicians may disagree with MAiD for personal or religious reasons; however, they are required to refer on to someone who can help. In Ontario, for example, there is a central referral service that doctors can use to access practitioners who are willing to see and assess patients who want assistance in dying.
Her daughter turns to me, and says, “She has always been a decisive person very in control in her life. I guess I can’t expect this to be any different?”
Despite the number of people accessing MAiD since the Supreme Court ruling, there’s ongoing discussion about the eligibility criteria. Some view it as too strict, not consistent with the spirit of the ruling, or ambiguous. And the conversation isn’t over — rules governing minors, people with mental health issues, and the ability to consent for future illness are still under consideration.
As the law stands now, an eligible patient must:
- be 18 years or older
- be capable of making health care decisions
- have a grievous and irremediable medical condition, which means:
- the patient has a serious and incurable illness, disease or disability, and
- the patient is in an advanced state of irreversible decline in capabilities, and
- the patient’s natural death has become reasonably foreseeable, andthe patient is enduring physical or psychological suffering, caused by the medical condition or the state of decline, that is intolerable to the person
- be making a voluntary request
- provide informed consent to medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.
This all means that patients must have a permanent medical condition that causes suffering and limits life expectancy. It is very important to understand that a request can only be made by a patient (not a substitute decision maker) who is found to be competent. Then, there is a mandatory, minimum 10-day waiting period between the request and the procedure. In most provinces, criteria have been set up to ensure that ‘medical tourism’ is avoided, meaning that patients must have valid health care coverage to prevent non residents from coming to Canada for MAiD.
Once a written request for MAiD is signed, there must be two independent physician assessments and completion of the 10-day waiting period. Then, MAiD can be provided at home, a long-term care home, hospice or hospital, although individual facilities may vary in their policies. Prior to administering drugs, the medical practitioner will offer a chance for the patient to withdraw consent and ensure they are still capable of making the decision.
Receiving medical assistance in dying is not a painful procedure and family members can be present if they wish. Depending on the province or territory, the death is reported to the coroner’s office and in most cases will not require investigation. There are opportunities for those who receive MAiD to donate organs and tissues after their death.
“I know it’s not for everyone, but this is the right choice for me.”
In the End
Choosing MAiD does not in any way restrict patient access to palliative care and the important end-of-life care that such a team provides. However, there is some debate that the availability and uptake of MAiD will undermine the importance and availability of palliative care in Canada. Moving forward, good coordination must occur between palliative care teams and MAiD professionals to provide the best care possible for patients.
Ensuring access to MAiD regardless of geography must also remain a priority. In remote areas, doctors or NPs may have to travel to reach a patient who requires care.
Finally, we must recognize that planning for one’s death is both foreign and surreal, and that there will be some some controversy in the acceptance of MAiD on both moral and religious grounds. However, for some patients, there can be great comfort in knowing that MAiD is available, and that, in Canada, it is now their right to explore this end-of-life path should they so choose.
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