Evidence of meeting #19 for Medical Assistance in Dying in the 44th Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was patients.
A video is available from Parliament.
Liberal
The Joint Chair Liberal Marc Garneau
Sorry to interrupt you, but we're having interpretation and sound quality issues.
Liberal
The Joint Chair Liberal Marc Garneau
On your screen, have you selected your headset as the audio input? It's going through your computer right now.
Do you know how to do that?
Physician, Collège des médecins du Québec
I'll check. The headset should be selected.
Liberal
The Joint Chair Liberal Marc Garneau
No. A technician will contact you. We will go on to Mr. Kekewich and come back to you after him, Dr. Roy.
Liberal
The Joint Chair Liberal Marc Garneau
With that, Mr. Kekewich, if you are ready, the floor is yours for five minutes.
Mike Kekewich Director, Champlain Regional MAID Network, Champlain Centre for Health Care Ethics, The Ottawa Hospital
Thank you very much, Mr. Chair and members of this committee.
Good morning, and good morning to my fellow panellists as well.
I'm the director of the Champlain Regional MAID Network here in Ottawa. We provide care to patients throughout the Champlain region, going from roughly Pembroke all the way to Hawkesbury. I'm also the director of the Champlain Centre for Health Care Ethics, both of which are hosted at the Ottawa Hospital here in town.
I'd like to make a few comments on what we're presently experiencing with respect to MAID, and then I'll talk a little bit about palliative care, given that's the subject of today's discussion.
First I want to comment on the most recent data from Health Canada, which shows that MAID continues to grow quite substantially from year to year, now representing 3.3% of deaths in Canada. We're seeing the same trend in our region and in this province, and it's very clear that more and more Canadians are inquiring about and accessing this service. I think we could continue to expect those numbers to grow as eligibility changes over time in terms of the law.
I do want to take just a quick moment to formally acknowledge the hard work of the clinicians across the country who are supporting patients and families through these very difficult decisions, particularly during this pandemic response period.
Ultimately, physicians; nurse practitioners; MAID navigators, as they're called, or coordinators; and other dedicated health care professionals are critical to the delivery of compassionate and high-quality care to patients who are requesting MAID.
I believe it's worth noting quickly that those who are actually assessing patients and providing MAID may not be as big a group of clinicians as people might think. In 2021, the total number of clinicians who provided at least one MAID procedure was 1,577, which initially sounds like a fairly comfortable number, but 35% provided only one MAID procedure, while just over 16% provided more than 10.
This is a challenge. It's a lot of stress on this dedicated group of clinicians. There were over 10,000 MAID provisions in 2021, and obviously there were a lot more assessments of patients moving through this process. There continues to be a substantial need for service from this group of clinicians.
In terms of palliative care, I would like to make a few comments.
Obviously I agree with the previous panellists. I had the opportunity to sit here and listen to them. Palliative care is an essential and critical service for Canadians and particularly for those who are considering MAID. I strongly believe—and have for many years—that MAID and palliative care are not mutually exclusive.
In my experience, many patients who are requesting MAID have historically received, or are currently receiving, very high-quality palliative care services that help them manage their suffering in a variety of ways. Many patients who are not receiving palliative care when requesting MAID are referred in that direction to give them the best possible care, regardless of what decision they ultimately make. Even for patients who ultimately do receive MAID, it's often the case that they continue to receive palliative care up until their final days to help alleviate their suffering, because MAID providers primarily act as consultants; they don't take over all of the responsibilities for caring for patients, in most cases.
I was encouraged to see in federal reporting over the last number of years that over 80% of MAID recipients had in fact received palliative care, with many of them receiving those services for one month or more, which I think is noteworthy.
In 2021, palliative care was identified as being accessible to 88% of those who received MAID in Canada, which I think is very encouraging.
Other localized studies and reports on this topic show, with some variability, that most patients requesting MAID were receiving palliative care or had access to it. I think it may also be the case that the introduction of the waiver of final consent, which was part of Bill C‑7, might have the effect of patients continuing to receive palliative care up until their final days, because historically some patients had been concerned about the requirement that they maintain capacity at the time that MAID is ultimately provided.
Obviously I'm encouraged by the data. I think there's still room for disagreement in terms of what would represent adequate access to palliative care for these patients; I don't feel particularly qualified to answer that question, but I believe that there is probably no such thing as too much access to palliative care services, and I think that probably transcends the conversation around patients who are requesting MAID, because it appears that they actually have quite good access to those services.
I will stop there. I am happy to receive any questions after the next panellist.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Mr. Kekewich.
Now we will go back to Dr. Roy.
Dr. Roy, you have the floor for five minutes.
Physician, Collège des médecins du Québec
Perfect, thank you.
I'm here to present the position of the Collège des médecins du Québec, where I've been working for a year and a half as an inspector in the Professional Inspection Division.
In light of the progress being made in granting access to medical assistance in dying and developments over the past few years, the Collège struck a working committee made up of clinicians. The committee began reflecting on MAiD in April 2021 and submitted its report in December 2021. The report was then endorsed by the board of directors.
I will now outline the findings and recommendations of the committee and the board.
First—and this has to do with the federal government, but also the Quebec provincial government— the Collège would like to note the harmonization issues between Quebec and Canadian law. The mismatch in choosing certain words causes confusion among health care providers.
For example, the Canadian legislation talks about an “illness, disease or disability”, while the Quebec legislation does not. It's causing many issues when it comes to interpreting the law. In addition, it could disqualify people who would normally be entitled to MAiD, based on which side of the Ottawa River they call home.
With respect to access to care, the working committee first looked into access to MAiD for persons with neurocognitive disorders, or progressive dementias. The committee and the Collège's board of directors supported advance requests when an individual becomes aware that they inevitably risk losing their faculties due to a progressive illness. People must therefore be able to submit an advance MAiD request, even if that means it is made several years prior to taking any action.
The second area for consideration had to do with MAiD individuals presenting a mental health issue only. Once again, the board of directors endorsed the recommendation that MAiD should only be available to people with a serious and persistent mental health condition for which treatment has been attempted and for which the individual sees no other outcome. Of course, this requires further thought about how to implement it. We need to make sure that the law is interpreted correctly and access to care respects people. We also need to make sure that all the necessary and possible care has been offered to an individual with mental health issues. In our current health care system, we know that access to mental health care can be problematic.
The third area for consideration was access to MAiD for emancipated minors between the ages of 14 and 17.
With support from the board of directors, the committee recommended that emancipated minors be able to apply for MAiD in conjunction with their parental authority or guardian. The pain that these young people may suffer must be taken into account; the suffering may become intolerable and it may no longer make sense in certain situations. The same is true for babies from birth to one year of age who come into the world with severe deformities and very serious syndromes for which the chances of survival are virtually nil, and which will cause so much pain that a decision must be made to not allow the child to suffer. In that respect, the committee highlighted the Netherlands' and other countries' experience. This avenue could be explored.
Finally, the committee considered the burden of living some elderly people carry. In geriatrics, we call it failure to thrive. For these individuals, life no longer makes any sense. Among other things, the fragility of life, diminished physical capabilities and existential pain become intolerable burdens. The committee and the Collège endorsed the idea of undertaking thorough reflection on this.
This is a topic that remains sensitive for the public and one for which we currently do not have clear answers on our side. Yet we want to be able to continue to have a joint reflection with learned societies and the general public to see under what circumstances this may be an option.
So I've presented to you here quickly, in a few minutes, the result of the reflections of the college's working committee, reflections that have been endorsed by its board of directors. The committee's work lasted six months, but it followed many years of reflection and work around this topic.
I am available to answer questions from committee members and provide clarifications.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Dr. Roy.
I will now turn it over to my co-chair, Senator Martin.
The Joint Chair Hon. Yonah Martin
Thank you.
Thank you, all three of you, for your testimonies. It will be very helpful to our committee work.
We'll begin our first round of questions with five minutes for Mr. Barrett.
Conservative
Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON
Thanks very much, Madam Chair.
Thank you to the witnesses for your time.
My first question is for Dr. Pereira.
Since MAID was legalized, have you had any experience of being prevented or impeded from applying a palliative care approach for someone who could have benefited from it?
Professor and Director, Division of Palliative Care, Department of Family Medicine, McMaster University, As an Individual
Yes, I have, and I've also had colleagues share similar experiences. I'll give you an example.
I was working for two years in a palliative care unit in my region, and in the palliative care unit, MAID is done. Patients are referred from other hospitals and other settings to the units to receive MAID. There were some occasions on which I saw patients I thought could benefit from palliative care, in that the treatment, the palliation, they received was suboptimal, and we could optimize it, but I was made to feel that I was obstructing access to it.
I think that does happen, and if you speak to colleagues, you will hear those examples.
That reminds me that I think a previous speaker said that most people who are requesting MAID are receiving palliative care. There are examples in which they arrive in palliative care units, and therefore on paper they are in a palliative care setting. However, they are not receiving palliative care; they are awaiting MAID.
I think we need to look at those numbers a bit more cautiously and closely.
Conservative
Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON
To pick up on something you said there, the distinction between palliative care and medical assistance in dying is one that has been noted by the board of directors of the Canadian Society of Palliative Care Physicians. International associations of palliative care state that distinction. Can you comment, then, on the intrusion of MAID into palliative care in the Canadian context, please?
Professor and Director, Division of Palliative Care, Department of Family Medicine, McMaster University, As an Individual
Yes. It's not only professional societies or associations of palliative care; it's also the World Health Organization that doesn't see MAID as part of it.
I believe that there is a distinction between the two. I understand that in a democratic society one can have access to it, but it doesn't mean that they have to be associated.
What I've seen is confusion around the two. For example, a few weeks ago I had a patient who had very advanced dementia and was on hemodialysis. She was in the final stages of her life and was still receiving hemodialysis. I met with the family and said that we needed to consider stopping hemodialysis, since it was not being helpful anymore. The family were very upset because they felt that I was promoting MAID. I had to spend a lot of time explaining that this is not MAID and we don't do MAID.
I also think that linking the two causes confusion. We are trying to move palliative care to earlier in the illness trajectory. This has been known since 2002. There's an emerging body of evidence showing the benefits of palliative care that is started months before the end of life. I think associating it with MAID keeps linking it to the very end of life.
I have seen resources being diverted. In one of the peripheral areas of the region that I live in, there have been nurses and nurse practitioners assigned to do MAID assistance, and therefore not enough health care professionals to assist patients for their palliative care needs and to address palliative care.
Conservative
Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON
Okay. To paraphrase, you would say that end-of-life resources that are going to MAID are in some cases being provided at the expense of palliative care offerings. Is that correct?
Professor and Director, Division of Palliative Care, Department of Family Medicine, McMaster University, As an Individual
Yes, Madam Chair, I would agree with that—
Conservative
Professor and Director, Division of Palliative Care, Department of Family Medicine, McMaster University, As an Individual
—in some cases.
Conservative
Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON
Madam Chair, how much time do I have left?
Conservative
Michael Barrett Conservative Leeds—Grenville—Thousand Islands and Rideau Lakes, ON
Okay.
Could you briefly speak to Canada's palliative care approach as compared to international examples that you have personal experience with, please?