The challenges & the practical side of implementing Medical Assistance In Dying (MAID)

BScN, RN, GNC(C) President,
Eldercare Home Health Inc.

Medical Assistance in Dying graphic

The legislation surrounding Medical Assistance In Dying (MAID) is still relatively new. The subject is very topical and brings out strong points of view from audience members – some might even say the topic is controversial.

There are as many questions as there are answers.

Eldercare Home Health sponsored medical Rounds on Medical Assistance In Dying one year ago at the North York General Hospital. The auditorium was as full then as it was this time around.

Some of the highlights of the presentation as well as my comments are below.

Background:

On June 16, 2016 the federal government passed legislation to amend Canada’s Criminal Code and established a federal framework for Medical Assistance in Dying (MAID) for individuals who meet pre-defined eligibility criteria.

What is MAID?

Medical Assistance in Dying is the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death

or

the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person at their request so that they may self-administer the substance, and in doing so, cause their own death. https://thewellhealth.ca/maid/

Eligibility for Medical Assistance In Dying

To be eligible for this ‘procedure’, patients must meet the following requirements:

  • Be at least 18 years old
  • Have a grievous and irremediable condition
  • The condition must be incurable and progressive
  • Suffering can be psychological or physical
  • Natural death must be foreseeable
  • The request for medical assistance in dying must be voluntary
  • Informed consent should include the offering of palliative care options
  • The person must be eligible for health services funded by government (to prevent medical tourism)

Low demand for this procedure

According to the presenter, Dr. Desmond Leung of the North York General Hospital Family & Community Medicine department, the number of recorded cases of medical assistance in dying in Ontario to date is 187. The majority were cancer related patients (122), followed by ALS patients (19).

North York General Hospital has had little experience with this ‘procedure’. As of the date of rounds, they have had one case of providing medical assistance in dying since the legislation has been established.

The case of medical assistance in death at North York General Hospital

The patient was a competent adult, who expressed a desire to die over a long admission. The patient was suffering from Chronic Obstructive Pulmonary Disease, difficulty breathing (dyspnea), and unremitting pain.

Two members of the team involved in this challenging clinical situation addressed the Rounds audience. They spoke about the actual procedural steps for providing medical assistance in dying, the provision in the legislation for health care professionals to object to participating in the procedure (conscientious objection) and they reviewed eligibility for patients wishing to access this procedure.

The procedural steps for Medical Assistance In Dying

Procedural steps are found on the professional practice sites of all of the regulated health care professions and are as follows;

A Clinician discusses and explores the request for Medical Assistance In Dying with the patient and provides information on all available treatment and care options.

If the patient chooses to proceed with Medical assistance in Dying, the patient completes and signs a formal written request (signed and dated by two independent witnesses).

  1. A documented Reflection period must be provided;
  2. A minimum of 10 days must pass between the day the formal written request is signed and the day that the lethal medication is administered or prescribed.
  3. In the meantime, an independent Second Clinician conducts a separate assessment of patient eligibility for MAID
  4. The clinician develops a plan for the administration of MAID, in consultation with the patient, family/caregivers (with consent), and other members of the care team (including the pharmacist)
  5. The clinician reaffirms that the patient is capable of making decisions related to their health, including the request and consent to proceed with MAID
  6. Immediately before administering injection or prescription for MAID, the Clinician:
  7. Confirms the patient’s expressed consent for MAID
  8. Provides the patient with the opportunity to withdraw the request
  9. The Clinician administers lethal injection or prescription for MAID

Other points of interest that were discussed;

It is a requirement that organ donation be discussed

All health care professionals may conscientiously object to assisting with this “procedure”. This includes not only the physician and nurse but also the pharmacist who prepares medication, social worker, dietitian etc.

If a health care professional objects to assisting with the procedure, the professional has an obligation to refer the patient to an appropriate resource (someone who does not object to participating)

Clinicians who choose not to provide MAID can either make a referral through their own professional networks or through MOHLTC’s Clinician Referral Service (CRS).

For example, the Ontario College of Pharmacists advises that in circumstances where a pharmacist declines to assist in MAID on the basis of a conscientious objection, he or she must provide the patient with an effective referral to a non-objecting alternate provider where the patient can receive the desired services in a timely manner.

Certification of Death and Reporting:

The clinician contacts Office of the Chief Coroner to report the death of a patient due to MAID. The Coroner obtains information from the Clinician and family to determine the need for examination of the body. Following the completion of a death investigation, the Coroner completes a death certificate.

An interesting and important question from a participant in Rounds concerned insurance:

“Would patients be disqualified from collecting life insurance payouts due to reason of suicide?”

A palliative care doctor from the audience stated that the death certificate would indicate that the cause of death was the medical diagnosis and not suicide. He also stated that the procedure of medical assistance in dying would not appear on the death certificate.

The following answer to this question is found on a government website for physicians in British Columbia;

How do I fill out the death certificate after providing medical assistance in dying?

ANSWER; In order to meet the requirement that medical assistance in dying is indicated on the Medical Certification of Death and that the cause of death is the underlying illness or disease causing the grievous and irremediable medical condition, the Vital Statistics Agency recommends that the Medical Certification of Death be completed as follows:

  • Report medical assistance in dying in PART 1 (a);
  • Report the underlying illness/disease causing the grievous and irremediable medical condition in PART I (b); and
  • Report manner of death as “natural.”

This response appears to agree, only in part, to the answer given by the palliative care doctor in the Rounds audience.

The guidance given above requires that medical assistance in dying be reported on the medical certification of death. As such, would insurance companies deny a life insurance payout, either fully or partially? How might a challenge from the insurance industry impact patients’ beneficiaries/dependents?

And the guidance below is taken from the Ontario Physicians and Surgeons of Ontario website:

STEP 9: Certification of Death:

As directed by the Coroner, in accordance with the Coroners Act, 1990, physicians are required to notify the Coroner of a medically assisted death and coroners are required to complete the Medical Certificate of Death in all cases where medical assistance in dying is provided.

As per the College of Physicians and Surgeons of Ontario, Physicians must disclose to their patients that the Office of the Chief Coroner will investigate all medically assisted deaths. The extent of a coroner’s investigation cannot be determined in advance, and may or may not include an autopsy.

Bill 84 appears to addresses the issue relating to insurance and other benefits:

13.9 (1) Subject to subsection (2), the fact that a person received medical assistance in dying may not be invoked as a reason to deny a right or refuse a benefit or any other sum which would otherwise be provided under a contract or statute.

2.2 For the purposes of this Act, a worker who receives medical assistance in dying is deemed to have died as a result of the injury or disease for which the worker was determined to be eligible to receive medical assistance in dying in accordance with paragraph 241.2 (3) (a) of the Criminal Code (Canada).

Advance Medical Directive and palliative care

At this time, a patient must be capable of consenting to MAID immediately before it is provided. For this reason, a person cannot consent to MAID through a living will or advance medical directive. Similarly, a substitute decision maker cannot consent to MAID on behalf of a patient. Family/caregivers or any other individual do not have the legal authority to consent to or authorize MAID on behalf of a patient.

Finally, it has been widely promoted that if good palliative care options were offered, very few patients would request medically assisted death. In fact, in jurisdictions where palliative patients can obtain a prescription for a combination of prescription drugs that would end their lives, only a very small percentage of patients ever fill that prescription. Palliative Care practitioners have long held that patients who are dying want some measure of control over their pain and suffering and that having a prescription at the ready reduces stress and anxiety that comes from being powerless.

Although a lot of work has been done in a very short period of time, the legislation is very new and practitioners in Ontario are inexperienced with the practice of Medical Assistance In Dying, possibly impacting accessibility to the procedure.

Additional information for Medical Assistance in Dying

For those interested in researching further, there are a number of resources available.

See our palliative care guide for information about palliative care at home

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