1. The Intersection of Medical Assistance in Dying (MAID) with Hospice Palliative Care
February 28, 2017

2. Objectives
Review the Supreme Court of Canada ruling regarding Physician Assisted Death - what does this mean for MDs?
MAID in Ontario since June 6th 2016
Current status of MAID in Waterloo Wellington LHIN
Suggest options regarding how an MD should approach a patient’s request for assisted death

3. Background
Feb. 6, 2015:
Carter decision by the Supreme Court of Canada
Feb. 6, 2016:
Initial Carter deadline
Apr 14, 2016: Federal legislation introduced
June 6, 2016: New Carter deadline (with four month extension)
January: Extension granted
June 2015 – Feb. 2016: Ontario consultation activities
Jan. – June. 2016: Extension period
February 6, 2015: the SCC in Carter v. Canada, unanimously struck down the Criminal Code prohibition against assisted dying to the extent that it “prohibits physician-assisted dying for a competent adult person who: (1) clearly consents to the termination of life, and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. The SCC suspended its decision for 12 months (to February 6, 2016) and explicitly stated that “it is for Parliament and the provincial legislatures to respond, should they so choose, by enacting legislation consistent with the constitutional parameters set out in these reasons.”
June 2015 – February 2016: Ontario conducted a series of consultation activities including extensive stakeholder engagement, market research, an online survey, and town-hall style public consultation across Ontario.
January 2016: In response to the federal government’s request for a six-month extension, the SCC granted a four- month extension to June 6, 2016.
Feb. 6, 2016 – June 6, 2016: During the extension period from February 6 – June 6, 2016, the SCC ruled that individuals who meet the Carter criteria are granted the right to apply to a superior court of justice in their respective jurisdictions for an individual exemption (during the extension period).
April 14, 2016: Federal legislation introduced
June 17, 2016: Federal Bill C-14 received Royal Assent.
Dec 7, 2016: Ontario introduces the Medical Assistance in Dying Statute Law Amendment Act, 2016.

4. Key Policy Issues
Between the federal government, Ontario, and relevant health regulatory colleges, the following issues (among others) will need to be addressed to support the creation of a comprehensive assisted dying system for Ontarians:
- 1 -
Eligibility Requirements
Age
Medical condition
Capacity to consent
- 2 -
Process for Service Provision
Role of health care providers
Assessment process
Competency timing
Safeguards for patients
Service provision locations
Appeal mechanism
Vulnerability assessment
Liability
- 3 -
Conscientious Objection and Effective Referrals
Referral networks
Support services
Regulatory college policies and guidance
- 4-
Oversight and Reporting Mechanism(s)
Reporting requirements
Oversight body
Public reporting
Death certificates
- 5 -
Access to Required Drugs
Guidelines
Distribution
Funding
- 6 -
Compensation Policies
Physicians
Institutions
Interprovincial billing
Public insurance status
- 7 -
Clinical Tools and Supports
Clinician forms
Educational materials and tools
Guidance from professional regulatory colleges and/or associations
- 8 -
Patient and Family Tools and Supports
Communications Materials
FAQs
Life Insurance
Bereavement supports 4

5. Provincial Landscape
Total number of cases completed in Ontario as of: January 31, 2017: 244
241 physician-administered cases
3 patient administered cases
155 Cancer-Related, 25 ALS, 24 Other Neurological, 25 CV/Resp., 10 Other
138 in hospital, 106 in home settings
Female: 130, Male: 114
Average Age: 73 (range )
Note: Does not include the 13 court authorized cases from February 6, 2016 to June 6, 2016, for which data is not available
*Home includes: residence, long term care centres and seniors/assisted living

6. Provincial Legislation
On Dec 9, 2016, The Ontario government introduced legislation (Bill 84) entitled the “Medical Assistance in Dying Statute Law Amendment Act, If passed, the Bill would amend six existing statutes in order to provide greater clarity and legal protections that would increase appropriate access to MAID in Ontario.
The proposed legislation would amend the following Acts:
The Coroners Act
The Excellent Care for All Act (ECFAA)
The Freedom of Information and Protection of Privacy Act (FIPPA)
The Municipal Freedom of Information and Protection of Privacy Act (MFIPPA)
The Vital Statistics Act (VSA)
The Workplace Safety and Insurance Act (WSIA)
Proposed Amendments
Coroners Act - Require that the Coroner be notified of all MAID deaths, but allow the Coroner to determine whether to investigate the death. The amendments would also require a review of the Coroner’s role by the Minister of MCSCS within two years of the amendments coming into force.
ECFAA
Provide that the fact a person received MAID cannot be invoked as a reason to deny a right or refuse a benefit that would otherwise be provided under a contract or statute. Clarifies that MAID may not be used as a reason to deny a payout on insurance or other benefits.
Provide statutory immunity for physicians and nurse practitioners and those who assist them in the lawful provision of MAID (except in cases of alleged negligence). Protects clinicians by deterring parties from bringing civil claims against clinicians and those assisting them in the lawful provision of MAID.
Freedom of Information and Protection of Privacy Act (FIPPA) & Municipal Freedom of Information and Protection of Privacy Act (MFIPPA) - Exclude identifying information about clinicians and facilities that provide MAID from the application of FIPPA and MFIPPA. Protects the identities of clinicians and institutions that provide MAID from being disclosed pursuant to an FOI request. This addresses some safety concerns arising from the fact that MAID remains a controversial issue.
Statistical (non-identifying) information could be disclosed outside of the Act. The MFIPPA amendment is to cover municipally-run long-term care homes, which are subject to MFIPPA and not FIPPA.
Vital Statistics Act - Amend the Vital Statistics Act to set requirements respecting the coroner’s documentation of MAID deaths consistent with the Coroners Act amendments. Clarifies that the Coroner does not need to sign the medical certificate of death for MAID deaths unless the Coroner investigates the death.
Workplace Safety and Insurance Act - Clarify that for the purposes of the Act, a worker who receives MAID is deemed to have died from the underlying injury or disease. Ensures that a claim made under the WSIA where the worker received MAID would be determined based on the illness or disease for which the worker was determined to be eligible to receive MAID and not another cause of death.

7. The Intersection of (MAID) with Hospice Palliative Care
Physician-hastened death is explicitly not a palliative care intervention per the World Health Organization definition and the Canadian Society of Palliative Care Physicians has affirmed that Palliative care does not include physician-hastened death.
Hospice Palliative Care is a philosophy of care that aims to relieve suffering and improve the quality of living and dying. It strives to help individuals and families to:
Address physical, psychological, social, spiritual and practical issues, and their associated expectations, needs, hopes and fears
Prepare for and manage end-of-life choices and the dying process
Cope with loss and grief
Treat all active issues
Prevent new issues from occurring
Promote opportunities for meaningful & valuable experiences, & personal and spiritual growth “Advancing High Quality, High Value Palliative Care In Ontario: A Declaration of Partnership and Commitment to Action”.

8. Medical Assistance in Dying in Ontario: CCO PPCCN Presentation
Is MAID part of Palliative & End-of-Life Care?
End-of-Life Continuum/Spectrum? If PC is a way to address suffering and MAID is also a way, are they part of the same continuum? Implies a blurring distinction between PC and MAID
Does continuum/spectrum imply a similarity between PC and MAID? If MAID is separate, does this stigmatize MAID?
Assistance in dying is unnecessary most of the time
Expressions of the wish to die, suicidal ideation or requests for MAID occur in about 8-22% 0f patients • In Oregon, 1% of terminally ill patients request MAID but only 0.1% actually die as a result of PAS* • In Holland, 17% patients with ALS chose to die with euthanasia, while 3% opted for PAS*Steinbrook, R. Physician- Assisted Suicide in Oregon – an uncertain future. NEJM. 2002; 346: •
What does the option of MAID mean for Palliative Care?
To reduce the requests for MAID, HCPs must:
introduce palliative care early in the illness trajectory
communicate early about goals of care
not miss out on windows of opportunity to introduce conversation about a patient’s suffering
always look for possibilities to withdraw life sustaining treatment
involve interprofessional team members
We have to bring ourselves to:
Respect our patients’ autonomy just as we want them to respect ours
Avoid confrontation at all costs
Not defer these discussions to other professionals or right-to-die associations
Understand that as physicians it is our job to talk about MAID
There is ample clinical and scientific evidence to show that even with the best possible palliative care, there will always be patients who will ask for help in ending their lives
Medical Assistance in Dying in Ontario: CCO PPCCN Presentation
February 9, Sandy Buchman MD CCFP (PC) FCFP, TemmyLatner Centre for Palliative Care

9. Key Messages from the Regional MAID Working Group
MAID and palliative care are distinct processes that may be accessed by patients concurrently.
Access to MAID is distinct from access to palliative care. Existing system resources / structures may be used to support referrals/access to MAID.
Experiences in Waterloo Wellington reveal that the patients who have pursued MAID, have not chosen palliative care OR MAID – they typically choose both.
Currently, some HPC providers are receiving MAID requests. In the absence of a defined process, Health Care Providers in all sectors are struggling to respond and support these requests. This is distressing and distracting these providers from delivering HPC. These providers describe feeling “unsupported” and “alone”.

10. Key Messages from the Regional MAID Working Group (Continued)
WW IHPC Regional Program is a key player in the development WW Regional MAID Framework to ensure that:
In all settings, the first next step after a request for hastened death is received is a comprehensive evaluation of the palliative care services that the patient has received to date.
High quality palliative care is provided to the patient and caregiver/family throughout the MAID/EOL experience (especially in anticipation of potential complex grief, loss and psychosocial issues - HPC providers are experts in addressing these issues).

11. Regional MAID Community of Practice MAID Request Navigation
DRAFT WW Regional MAID Framework
#1 Central Access Point
Referrals may come from patients or care providers in acute care, post acute care, hospice, community, primary care, LTC
Regional MAID Community of Practice
MAID Request Navigation
Navigate Referral to:
MAID Supporting Primary Care Provider OR
Sub Region MAID Resource Group
Guelph
Sub Region Process
Rural Wellington Sub Region Process
Cambridge/ North Dumfries
Sub Region Process
Kitchener Waterloo
Sub Region Process
#2 Patient Request to Provider – Provider Supports MAID Request and/or Connects Patient with Sub Region Process

12. The Centre for Effective Practice has developed a tool to provide additional guidance to clinicians on MAID provision and process, including a full pathway for MAID.

13. Medical Assistance in Dying - CASE # 1:
63 yr old man presents to family doctor with back pain. Numerous investigations reveal metastatic cancer involving bone, liver, lungs. Biopsy proven NSCL cancer.
Referral made to Cancer Program. Patient seen by oncologist diagnosis and possible treatment options discussed. Patient identified as having ++pain with poor control therefore, admitted to inpatient ward at hospital for PSM.
In hospital referral made to palliative/pain and symptom management team. Hints to MRP (ward GPO) that feels strongly about MAID and may not be interested in treatment options as discussed with oncologist previously.

17. WW MAID Tools (As per steps in the CEP Guideline)

18. Other Tools to Support MAID

19. MAID Process - Role of Receiver of Request
Where a physician declines to provide medical assistance in dying for reasons of conscience or religion, the physician must do so in a manner that respects patient dignity. Physicians must not impede access to medical assistance in dying, even if it conflicts with their conscience or religious beliefs.
The physician must communicate his/her objection to medical assistance in dying to the patient directly and with sensitivity.  The physician must inform the patient that the objection is due to personal and not clinical reasons.  In the course of communicating an objection, physicians must not express personal moral judgments about the beliefs, lifestyle, identity or characteristics of the patient.
CPSO policy statement #4-16

20. MAID Process - Role of Receiver of Request (cont’d)
In order to uphold patient autonomy and facilitate the decision-making process, physicians must provide the patient with information about all options for care that may be available or appropriate to meet the patient’s clinical needs, concerns, and/or wishes.  Physicians must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.
Where a physician declines to provide medical assistance in dying for reasons of conscience or religion, the physician must not abandon the patient. An effective referral must be provided. An effective referral means a referral made in good faith, to a non-objecting, available, and accessible physician, nurse practitioner or agency. The referral must be made in a timely manner to allow the patient to access medical assistance in dying. Patients must not be exposed to adverse clinical outcomes due to delayed referrals CPSO policy statement #4-16

21. MAID Process – Next Steps
Patient makes initial inquiry for medical assistance in dying to a physician or a nurse practitioner
Physician or nurse practitioner assesses the patient against eligibility criteria for medical assistance in dying.
Patient makes written request for medical assistance in dying before two independent witnesses (Clinician Aid A)
The physician or nurse practitioner must remind the patient of his/her ability to rescind the request at any time.
An independent second physician or nurse practitioner confirms, in writing, that the patient meets the eligibility criteria for medical assistance in dying.
A 10-day period of reflection from date of request to provision of medical assistance in dying.
Physician or nurse practitioner informs dispensing pharmacist that prescribed substance is intended for medical assistance in dying
Provision of Medical Assistance in Dying
Certification of Death
#3 - Clinician Aid A - Review documentation ie: who can be witness and what they are witnessing (I know we have had some confusion about this in the past).
#5 - Review who can and cannot be second assessor
#6 - Review special circumstances

22. Criteria for Medical Assistance in Dying
In accordance with federal legislation, for an individual to access medical assistance in dying, he/she must:
Be eligible for publicly funded health services in Canada;
Be at least 18 years of age and capable of making decisions with respect to their health;
Have a grievous and irremediable medical condition (including an illness, disease or disability);* Review definition/criteria for irremediable suffering as per CPSO document.
Make a voluntary request for medical assistance in dying that is not the result of external pressure; and
Provide 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.

23. Medical Assistance in Dying - CASE # 2:
61 year old woman diagnosed in March 2016 with hepatobiliary cancer in the context of primary biliary cirrhosis diagnosed in Followed by a gastroenterologist and a primary biliary cirrhosis clinic in Toronto.
Relatively well until March 2016 when she began experiencing progressive abdominal discomfort, weight loss, anorexia and nausea. Underwent an abdominal ultrasound in April 2016 revealing nothing consequential.
Repeated ultrasound in August 2016 revealing multiple liver lesions. A subsequent MRI confirmed lesions to both hepatic lobes and to the head of the pancreas.

24. Medical Assistance in Dying - CASE # 2:
November, 2016: Met with a medical oncologist to explore the role of systemic therapy. She refused all disease modifying and palliative systemic therapies with the understanding that her disease is incurable and optimal treatment circumstances would extend her life by only weeks to months. She does not want to “prolong suffering and the dying process”. Eva requested a “do not resuscitate” status and requested medical assistance in dying (MAID).
The medical oncologist initiated the referred to community hospice palliative care team with palliative nursing through CCAC.
Late November 2016: After meet several times with Eva to review Eva’s wishes and her sense of suffering, the palliative care physician initiated a referral with the MOHLTC Clinician Referral Line for 2 independent assessments of Eva’s eligibility for MAID.
Early December 2016: First and second independent assessments performed to determine Eva’s eligibility for MAID.

25. Medical Assistance in Dying - CASE # 2:
Social Background
Eva and John have been married for 25 years. They have 2 supportive sons who live in Toronto and London – A second grandchild is expected to be born in late February. Both sons are aware of Eva’s illness, prognosis and her request for MAID and are supportive of her wishes.
Request for MAID, Understanding of her Health Circumstances
Eva has a clear understanding of the progressive and life-limiting nature of her illness. From her discussion with the medical oncologist in November, she believes that her prognosis is measured in weeks to months and would not be prolonged with treatment - in what Eva considers a meaningful way.
Both she and John have noticed a decline in recent weeks in her energy, stamina and overall sense of well-being. More than this, Eva clearly and calmly articulates that she and John discussed years ago that should either of them hypothetically become terminally ill, they would want to shorten life and minimize a protracted period of decline and physical/psychological suffering

26. Hope is the only thing stronger than fear……
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Emmi Perkins
Director, Waterloo Wellington Integrated Hospice Palliative Care Regional Program
Hope is the only thing stronger than fear……