Medical Assistance in Dying Committee on Sept. 23rd, 2022

[Dr. Natalie Le Sage]

Thank you for the question.

My experience in the field has allowed me to assess patients suffering from physical illnesses and their eligibility for MAID under the current law. I have also assessed patients who, despite the fact that they mainly suffered from a physical illness and met all the eligibility criteria, also had a secondary a mental disorder that required a psychiatric assessment. We have to look at the various aspects that, when we are dealing with a mental disorder, as was stated previously, are a bit trickier.

I observed that in many cases, the attitude of healthcare professionals was different when dealing with patients suffering from a mental disorder. They didn't even see anymore the physical health problem that made those persons eligible for MAID. Even if the patients were not suicidal, even if they were lucid and met all the criteria, those patients were sometimes discriminated against because of their mental health issues. Oftentimes, this even had a discernable impact by pushing back the moment when their request for MAID was heard. That was the form of discrimination that I observed.

As we have been saying from the beginning, I think that the cases where a mental disorder is the sole underlying condition are exceptional ones. All psychiatrists are saying that to close the door on these patients is tantamount to not listening or not being empathetic to their suffering. To me, as a doctor, that is unacceptable.

[Marie-Françoise Mégie]

Thank you.

If I have any speaking time left, I would like to give it to Senator Dalphond.

[The Joint Chair, Liberal, Marc Garneau]

That's fine.

Senator Dalphond, you have in total about eight and a half minutes.

[Pierre Dalphond]

Thank you, Chair.

We have spoken about many subjects, so I am not sure I will need all the time given to me. The witnesses do not have to feel rushed.

My first questions will be for Dr. Dembo.

You are a member of the task force, and that group has come up with a substantive report. Are you confident that the task force guidelines are sufficient? Certainly I have followed some criticism that was expressed further to the release of the report. Has this brought you to change your mind or to say, “Maybe we should have also said something about the following issues”?

Is there something you would like to say? Would you say, “Our task force report is fine; its guidelines are sufficient” or “After further thought, I will recommend that we have the following”?

[Marie-Françoise Mégie]

Thank you for that question.

Yes, I believe that the expert panel recommendations are very comprehensive and thorough. I have thought about that at length, and I can't think of anything that I would want to add or feel the need to add. Partly, I say that because I think the pre-existing safeguards that are already in place for track two are quite thorough if they are followed appropriately by assessors and providers.

Along with the recommendation in the panel report that assessors and providers be trained in a standardized way.... I hope you know that there are training programs being developed, and I'm part of the development of those training modules. If assessors receive that additional training, they can provide assessments in a more standardized way and they can follow the existing guidelines and the safeguards that are already there, plus the additional elements that are added in through the panel report, which refine what is already there and allow assessors to interpret the current legislation even more clearly.

I am quite satisfied with the way the report elaborates on that. My only concern is making sure that it is followed and that the recommendations are implemented locally.

[Pierre Dalphond]

I understand—Dr. Le Sage referred to it before—that when there is comorbidity and we have somebody who is on track two, the process involves an assessment of the ability to consent and the need to make sure that the request is not based on improper mental reasons, but is based on comorbidity. You have to do a mental assessment.

In other words, is the practice already familiar, to a certain extent, of assessing mental conditions as a cause for access to MAID?

[Marie-Françoise Mégie]

Is that question for me as well?

[Pierre Dalphond]

Yes.

[Marie-Françoise Mégie]

Thank you.

Yes, I think that's actually a very important point. We have already been assessing capacity for MAID in people who have serious mental health conditions and who have a comorbid physical disorder that makes them eligible. That's not just on track two, but also on track one.

Psychiatrists are trained in capacity assessment, to begin with, in other highly consequential medical decisions such as withdrawal of life support or the ability to refuse life-sustaining treatment, so I think much of this is already familiar. There are always going to be nuances, but I don't think those nuances are specific to the diagnosis, such as a diagnosis of mental illness. The nuance is going to be specific to each patient in each of their own unique circumstances.

[Pierre Dalphond]

In a sense, when we transition in March to having access to track two, including for those whose sole condition is a mental condition, the system won't be taken by surprise in a completely new setting that they were not familiar with. That's what I understand from your answer.

[Marie-Françoise Mégie]

My sense is that those of us who have been providing assessments for track two will not feel surprised.

I do think the system will struggle, because my understanding is that there are very few assessors right now who feel willing to accept those cases, so there will be a bottleneck in terms of the number of applications versus the psychiatrists willing to do those assessments.

I don't see that as a terribly negative thing. It does absolutely put up an obstacle, but on the other hand it allows for assessments to be more longitudinal, just naturally, as it unfolds.

[Pierre Dalphond]

Thank you.

Doctor Le Sage, my next question is for you.

Some witnesses were concerned by the fact that certain mental disorders are associated with suicidal tendencies. You touched upon this earlier. In those cases, what do you do to keep that person from being eligible for MAID?

One of the arguments against that we regularly hear is that this would allow people who are suicidal to request MAID.

[Dr. Natalie Le Sage]

At the risk of repeating myself, we do not assess people when they are in crisis. At the ER, I have seen numerous patients who have reached a crisis point. Those patients who are going through an acute phase would not become eligible.

I will now put on my hat as a MAID provider and assessor.

When a patient goes through an acute suicidal crisis, he or she is not eligible for MAID. We assess a patient who may have had a cluster of repeated crises as well as long and frequent periods of hospitalization. Because that person is able and not suicidal, he or she will talk about their suffering. The patient would be assessed by an entire team and by his or her psychiatrist. We are not talking about a situation where the patient is acutely suicidal. These patients do not have access to MAID. There's not a single provider who would consider that such a patient would be eligible.

[Pierre Dalphond]

I have another question for you, Doctor Le Sage.

Yesterday, I watched the Quebec election debate. All the candidates talked about a particular topic, which is the lack of resources for mental health.

Is there a risk that current resources, which are perhaps already insufficient, would be used to assess requests for MAID, which would aggravate the problem? Is the system able to handle the additional load of requests for MAID in cases of mental disorders?

[Dr. Natalie Le Sage]

I will once again make the analogy with a physical illness.

Contrary to what other have stated, since MAID has been authorized in our country, palliative care, which consists of treatment and support, has probably been offered more frequently, rather than the opposite. When we assess MAID requests, we are required to make sure that the patient has had access to various care options. We must ensure that their suffering is not linked to the fact that there are gaps in the provision of healthcare. We see that the patients are already receiving palliative care but that they no longer wish to, or that such care has been offered to them but they would prefer to have MAID.

In the case of a patient whose sole underlying condition is a mental disorder, we are obligated to assess if there's something missing within the care on offer. We have to make sure that all resources have been used to help the patient.

All psychiatrists have been saying that these cases are rather rare, and the people would have received support from the healthcare system and would have had access to resources over many years.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Doctor Le Sage.

This brings us to the end of our second panel. I would like to thank our—

[Marie-Françoise Mégie]

Mr. Chair, pardon me, but I have a quick question for Dr. Dembo.

[The Joint Chair, Liberal, Marc Garneau]

Go ahead, Senator Mégie.

[Marie-Françoise Mégie]

Doctor Dembo, I believe you have a document that sums up the various steps included in the process. This document would be most useful to our committee. Would you be able to forward it to one of the committee clerks?

[Marie-Françoise Mégie]

Absolutely. I'd be happy to send them later today.

[Marie-Françoise Mégie]

Thank you.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Dr. Dembo.

I'd like to thank Dr. Dembo and Dr. Le Sage.

Thank you for sharing your time and your expertise with us today. Thank you also for answering our questions pertaining to our extremely important study.

We very much appreciate that you took the time to be with us to answer all of our questions.

With that, this committee is adjourned.

Thank you.