Medical Aid In Dying - Developing a Framework Plenary #1 Delivering Medical Aid In Dying: Delivering Medical Aid In Dying: The Big Issues Temmy Latner Centre for Palliative Care1 October 27, 2015 Sandy Buchman MD CCFP FCFP

Objectives To offer the practicing physician’s perspective on physician-assisted dying (PAD)To offer the practicing physician’s perspective on physician-assisted dying (PAD) To offer some suggestions on designing a legal framework to support the choice of physicians to participateTo offer some suggestions on designing a legal framework to support the choice of physicians to participate To comment on certain aspects of proposed legislation such as education, language and organ transplantation after PADTo comment on certain aspects of proposed legislation such as education, language and organ transplantation after PAD Temmy Latner Centre for Palliative Care2

“Physician-Centric” What kind of legislative framework will it take to… Allow me to comfortably agree to participate in physician assisted dying?Allow me to comfortably agree to participate in physician assisted dying? Persuade a new physician to participate?Persuade a new physician to participate? Allow me to remain involved for the duration of my career?Allow me to remain involved for the duration of my career? Allow a sufficient number of physicians to participate to meet society’s needs for this service?Allow a sufficient number of physicians to participate to meet society’s needs for this service? Temmy Latner Centre for Palliative Care3

PAD: Effects on the Living? Temmy Latner Centre for Palliative Care4

PAD: Impact on Physicians Emotions: uncertainty, loss, fear of technical failingsuncertainty, loss, fear of technical failings Impact of participation on one’s reputation (both pro and con) with one’s colleagues (intra and interprofessional), family and communityImpact of participation on one’s reputation (both pro and con) with one’s colleagues (intra and interprofessional), family and community lack of clarity re my duty to my patient – duties to refer and duties to informlack of clarity re my duty to my patient – duties to refer and duties to inform Temmy Latner Centre for Palliative Care5

PAD: Impact on Physicians Trust/Therapeutic Alliance: Is there trust lost between doctor and patient (those that don’t want PAD?) –Is there trust lost between doctor and patient (those that don’t want PAD?) – If I become known as an MD who undertake PAD… If I become known as an MD who undertake PAD… –how will that effect their trust of me as their physician? –How will their families’ regard me? Will trust be eroded? Temmy Latner Centre for Palliative Care6

Legislation helps… Permits “someone” to watch over youPermits “someone” to watch over you Enhances trust when followed conscientiouslyEnhances trust when followed conscientiously Should the legislation place all the burden and responsibility on the individual physician?Should the legislation place all the burden and responsibility on the individual physician? –Suggest that the legislation could make the decision to become involved a ‘team” responsibility Temmy Latner Centre for Palliative Care7

Assessment: Exploring the Request Patient factors: Formal evaluation of cognitive status/capacityFormal evaluation of cognitive status/capacity Formal evaluation for any psychiatric condition that may impair capacity or autonomyFormal evaluation for any psychiatric condition that may impair capacity or autonomy Patient’s request will be made known to the patient’s SDMPatient’s request will be made known to the patient’s SDM No evidence or suspicion of patient coercion o manipulation to promote the request for PADNo evidence or suspicion of patient coercion o manipulation to promote the request for PAD Temmy Latner Centre for Palliative Care8

Assessment: Exploring the Request Disease related factors: Treatment has been offered either previously or currently and acknowledged by the patientTreatment has been offered either previously or currently and acknowledged by the patient Rejection of treatment must be documentedRejection of treatment must be documented Temmy Latner Centre for Palliative Care9

Processing the Request 2 nd opinion from another MD is mandatory for each request within a reasonable time period (1-2 weeks)2 nd opinion from another MD is mandatory for each request within a reasonable time period (1-2 weeks) 2 nd physician uses the same template as the first in all domains2 nd physician uses the same template as the first in all domains Temmy Latner Centre for Palliative Care10

Provision of Assisted Death The patient will review with the physician the procedure for provision of assisted death Sign (witnessed by a third party) consent form indicating agreement Legislation must address the involvement of other professionals (Nurses, NPs, Pharmacists) RN and MD (or their substitutes) willing to participate must be easily accessible/available if needed Centre for Palliative Care11

Provision of Assisted Death There can no ingestion of lethal medication unless both RN and MD available/accessible MD must remain accessible until the patient expires If hastened death is lethal provision, the MD administers the medication and remains until the patient’s death Formal documentation and reporting to oversight body is mandatory & described by regulation Temmy Latner Centre for Palliative Care12

Pronouncement Coroner to be notifiedCoroner to be notified Cause of death on death certificates to be determined: disease or lethal ingestion or injectionCause of death on death certificates to be determined: disease or lethal ingestion or injection Temmy Latner Centre for Palliative Care13

Education For all practicing physicians who intend to provide PAD as well as and all trainees: Competencies/Learning Objectives: – –Consider ethics around PAD – –Understand the legal and regulatory frameworks for PAD – –Understand the process of referral, assessment and delivery of PAD – –Develop competency in discussing options at the end of life, including PAD – –Understand pharmacology of PAD – –Understand how to deal with complications of PAD For all those who will not participate, basic training in “how to have the conversation” regarding a duty to inform is recommended Temmy Latner Centre for Palliative Care14

Organ Transplant after PAD Potential solution to the organ scarcity problem although numbers likely to be smallPotential solution to the organ scarcity problem although numbers likely to be small Must be addressed in any legislative frameworkMust be addressed in any legislative framework Must insist that a physician who facilitates in any way the provision of PAD will not benefit from the death of the patient*Must insist that a physician who facilitates in any way the provision of PAD will not benefit from the death of the patient* Temmy Latner Centre for Palliative Care15 * Swiss Penal Code

Language Palliative care MDs provide medical aid in dying dailyPalliative care MDs provide medical aid in dying daily Terms assisted dying, physician assisted dying and assisted death are impreciseTerms assisted dying, physician assisted dying and assisted death are imprecise Patients may believe that assisted death = hastened deathPatients may believe that assisted death = hastened death Suggest:Suggest: –Patient administered, physician-hastened death to replace physician assisted suicide –Physician administered, physician-hastened death to replace euthanasia –Physician-hastened death to replace assisted dying –Medically-prescribed death could be an option if other professions are involved Temmy Latner Centre for Palliative Care16 Canadian Society of Palliative care Physicians. Messages-FINAL.pdfhttp:// Messages-FINAL.pdf Accessed October 24, 2015

Summary Consider the humanity of and impact upon any physician who agrees to participate in PADConsider the humanity of and impact upon any physician who agrees to participate in PAD Design a legislative framework to support and sustain the physician’s decision to participateDesign a legislative framework to support and sustain the physician’s decision to participate Describe a clear PAD process to be included in the legislative framework from the initial request to the provision of PAD to the processes after deathDescribe a clear PAD process to be included in the legislative framework from the initial request to the provision of PAD to the processes after death Obligatory training in managing a request for PAD, organ transplantation after PAD and attention to language need to be consideredObligatory training in managing a request for PAD, organ transplantation after PAD and attention to language need to be considered******** Temmy Latner Centre for Palliative Care17