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

[Luc Thériault, Bloc, Montcalm, QC]

It is for you.

[Dr. Natalie Le Sage]

As has been stated innumerable times, these patients have already been assessed by at least one if not more psychiatrists. We can therefore presume that the patients eligible for MAID are suffering from a grievous illness. I would remind you that these are grievous and incurable illnesses. To require more assessments in a remote region, or even in a city, could create a barrier. Such an assessment would not provide any more information and would not make the process any more thorough.

[Luc Thériault, Bloc, Montcalm, QC]

Is the March 2023 deadline realistic? Given your experience in the field, will we be able to provide this service and to do the work properly by March 2023?

My question is for Dr. Dembo.

[Marie-Françoise Mégie]

Thank you for that question.

Whether or not March 2023 is a realistic deadline depends on how committed and efficient various provincial and local bodies can be in implementing guidelines based on the panel's reports. I'm hoping they can do that.

I would also say, though, putting that aside, that MAID assessors and providers have been assessing patients on track two for quite some time now, and the issues that come up in track two and mental illness are very similar. I actually think that already assessors and providers are getting practice and are prepared to be able to implement the recommendations by March 2023.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Before I turn to Mr. MacGregor, I'm going to also turn it over to our co-chair, Monsieur Garneau.

Mr. MacGregor, you have five minutes.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you very much, Madam Chair.

Thank you to Dr. Dembo and Dr. Le Sage for guiding our committee through this subject matter.

Dr. Dembo, I'd like to start with you. In the history you have in treating patients and with how intimately familiar you are with some of their conditions and so on, as a percentage of the patients you have seen, how many would you say would actually qualify for medical assistance in dying where a mental disorder is the sole underlying condition? We're just trying to get a sense of what the population would be in this regard.

[Marie-Françoise Mégie]

That's an important question and a difficult one to answer, because the law has not yet changed. That said, I think of the patients I see overall. I work with a population of highly treatment-resistant patients with OCD who get sent to our tertiary care centre. Most of them have other comorbid illnesses like depression that is also severe. Some of them have talked with me about MAID for sole mental illness, and I follow a few who ultimately would like to proceed.

I'd say the percentage who would likely be eligible is relatively small, of those I follow at this time who would like to proceed with MAID. But I would also say that the percentage of patients with severe psychiatric illness who ultimately would want to even be assessed for MAID is very small, and the percentage of people who have irremediable conditions is small.

I can't give you a number, but I would say that the majority of people who would apply would probably not be eligible, based on what I'm seeing the applications might look like.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you for that. That was an answer.

We've heard concerns about the fact that, like every other field of medicine, the development of treatments is always expanding. New research is going on, etc. I guess some of our witnesses have related their concern that someone could qualify for medical assistance in dying, and then maybe in a few years' time a treatment comes out that is successful in treating that condition—we don't yet know.

Can you clarify whether physicians, especially assessors, would consider it a duty of care to have done their research into the most advanced state of research that's available for treatment right now? Can you just expand on that a bit more?

[Marie-Françoise Mégie]

I'd say that in any aspect of medicine there's always the chance that another treatment is around the corner that could cure or significantly help that patient, and any patient making a decision about withdrawal of life support or MAID or other highly consequential decisions does run the risk of missing out on something that may have helped a few years in the future. Part of assessing the capacity to make these decisions includes an assessment of the person's ability to understand that.

I think I lost track of the second part of your question. Could I ask you to repeat it?

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

It was just whether it's considered a duty of care to be apprised of all the latest research in treatment.

[Marie-Françoise Mégie]

Yes, I believe it is. In the reading of the expert panel report, I hope it comes across that in one of our recommendations not only do we suggest an independent psychiatrist who's an expert in the condition, but we may sometimes require two psychiatrists or a subspecialist consultation to make sure that no stone has been left unturned, and to make sure that someone with expertise in that person's specific psychiatric condition would also be able to assess and provide information on the most recent or even experimental treatments that might be worth trying before proceeding with MAID.

That is certainly how I handle it, clinically, and how my colleagues handle it.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you.

Finally, you provided an answer on the March date that is rapidly approaching, but we've already produced an interim report on this subject. There has been a flurry of other reports, as well.

What do you think this parliamentary committee should be producing, specifically, in terms of recommendations to the federal government when we get to the point where we're ready to table our final report?

[Marie-Françoise Mégie]

I hope I understand your question correctly.

My inclination is to say that I very much stand behind all of the recommendations we made on the expert panel, and I would hope those recommendations are translated into guidance items and protocols for provincial and local authorities to follow, once they start receiving these MAID requests. I think that needs to be implemented, and I would like to see that moving faster than it is.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Mr. MacGregor.

I will now turn over to the senators. Because there are only two of them, I will give each senator a maximum of seven and a half minutes. We will start with Senator Mégie.

Senator Mégie, you have the floor.

[Marie-Françoise Mégie]

Thank you, Chair.

My first question is for Dr. Dembo.

Doctor Dembo, seeing as you work in the field and that you are also involved in research, I would like you to describe the process that allows you to assess the eligibility of someone for MAID and ask you to describe the time required for each step. When we were talking about the general population, we spoke of the length of time for each step, and of the fact that the period could be extended, et cetera. Please tell us about the length of each step for persons suffering from mental disorders.

[Marie-Françoise Mégie]

Am I correct in thinking that question was for me?

[Marie-Françoise Mégie]

Yes.

[Marie-Françoise Mégie]

Thank you.

May I ask if it would be all right for me to partly read from something I previously prepared, where I walk through the process of a MAID assessment, or would you prefer I were brief?

[Marie-Françoise Mégie]

Could you tell us a bit more about the length of time for these steps?

You may be brief.

[Marie-Françoise Mégie]

I'm so sorry. The interpretation just disappeared.

[The Joint Chair, Liberal, Marc Garneau]

Please summarize, Dr. Dembo.

[Marie-Françoise Mégie]

It really depends on the patient. Remember that, right now, we are not assessing people for sole mental illness, but rather using patients on track two as examples. I can expand on how that might apply.

The first step is always gathering the information provided by the person referring the patient to me. That takes a lot of work: reading through all the person's previous charts provided to me, and the reasons for the referral. Then there is a meeting with the patient. The initial meeting is usually two hours, and that's usually not the only time we meet. I suspect, for sole mental illness, it will be much more than just a few meetings—probably several two-hour meetings over the span of months or possibly years. It could be a very lengthy time span, as it has been with track two.

In between steps, one wants to look at whether a patient has been offered appropriate treatments and has seriously considered them. This can involve having them go through certain interventions—not just medical treatments, but interventions involving finance, housing and social supports. All of that takes time to put into place. These serial assessments would occur over a long period of time, in my view.

I hope that helps.

[Marie-Françoise Mégie]

Yes, thank you.

I better understand why the barriers would be doubled if a second psychiatric assessment were required. Have I understood correctly?

[Marie-Françoise Mégie]

There are real obstacles to obtaining psychiatric assessments for MAID right now, even for track two patients. I expect there will be delays for patients who are waiting for an expert psychiatric opinion on their MAID request for mental illness, especially if a second specialist is required. That's another delay. I think that, right now, the way things are, it's unavoidable.

[Marie-Françoise Mégie]

Thank you.

My second question is for Dr. Le Sage.

Doctor Le Sage, as you know, people suffering from mental disorders are often stigmatized in our society. You have indicated that the exclusion of these persons is actually discriminatory. In your opinion, how could excluding them increase their stigmatization?

Do you have a concrete example to give us in light of your experience in the field?