Medical Assistance in Dying Committee on Oct. 7th, 2022

[Dr. James Downar]

If I may, I would like to add some quick comments on the situation outside of Quebec. There are problems everywhere in Canada, but we have a few ways of filling the gaps in the system.

Here in Ontario, there are many teams and various models to support patients at home. You asked what it would take to help those patients at home. As Dr. Dechêne said, oftentimes, there aren't enough doctors in the community who make house calls. It is therefore important to have a team which has the necessary skills to meet patients' needs. That could be a nurse practitioner.

For example, nurse practitioners or nurses who have the necessary skill set are able to meet the needs of patients. A family doctor can be supported by a consultant specialist who would be on call to give advice in order to help manage certain situations. In the case of patients whose needs are more complex, teams of doctors specialized in palliative care can make house calls. Often, though, these specialists are only present in urban communities, as you stated.

There are many models. As Dr. Dechêne said, it is important to find models that offer rewards. It is sometimes difficult for doctors to earn a good living when they make house calls, because house calls don't pay very much. Renumeration schemes do exist, however, especially in Ontario.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

We'll now go to Monsieur Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

My question is for Dr. Dechêne.

It is most refreshing to hear what you have to say, given that Quebec's Act Respecting End-of-Life Care was brought into being in order to put an end to the argument opposing palliative care and medical assistance in dying. This is most interesting because your comments are entirely based on this aspect and validate my own opinion on the subject.

What is the situation currently? We have a hospital-based system. This means that a person's last moments usually take place in a hospital. From what I understand from your presentation, if there were palliative care on offer and everyone had access to it, there would be no more medical assistance in dying because no one would request it. That is the argument used by those that oppose medical assistance in dying.

Could you be brief in your reply, because I have a few more questions to ask.

[Dr. Geneviève Dechêne]

You are absolutely right.

In Quebec, the proportion of all deaths by MAID is at 3.4%, and I believe that we will get to the Belgian or Swiss average, which is 4% to 5%. I agree with this, because we have to respect the will of our patients.

I will be brief. If patients, as it often happens, do ask for MAID because no doctor is available to ease their pain, then that is less acceptable to me.

[Luc Thériault, Bloc, Montcalm, QC]

All right.

Correct me if I'm wrong or if you don't agree with what I'm going to say, but in the end, medical assistance in dying should be seen as part of the continuum of care.

People sometimes say that patients request medical assistance in dying because palliative care is missing. A dying patient does not have access to palliative care and therefore requests medical assistance in dying.

But palliative care, when seen as part and parcel of accompanying a person toward death, and I would also ask that you define this notion, could be such that at a given time, a patient may be ready to let go. Because that patient has received good palliative care, has been well supported on his or her journey toward death and is completely at peace, that person could then decide that today is the day that he or she lets go and would like to depart this earth.

The example I've given you does not constitute a failure of palliative care. It could be seen as a success story for palliative care because, all of a sudden, the patient is completely at ease with letting go and requests MAID.

Do you agree with this?

[Dr. Geneviève Dechêne]

The words “let go” don't sit well with me because 96% or 97% of our patients do not request MAID. I'm not ready to say that they “hung on.” The expression doesn't sit well with me. I think we should see the end of our life as...

[Luc Thériault, Bloc, Montcalm, QC]

Pardon me for interrupting you.

Someone told me that an approach based on self-determination is actually a very controlling approach to death, because that person wants to control his or her death till the very end. The person told me that we are obsessed with controlling death and that is the reason people are requesting MAID. But really, when a person gets up in the morning and feels totally at peace with his or her decision to go, that is letting go. It does not exclude a person who wants to keep on living until the end. That is not the issue here.

[Dr. Geneviève Dechêne]

The vast majority of people want to continue living until the very end because they know that we will be there, that we are there to reassure them and that we will know how to ease their pain during the care journey up until the end.

I would like to state as well that because we are not lacking nurses and doctors, the patients that are being accompanied do not feel abandoned by the health care system. I would add that we offer palliative care elsewhere in Quebec, in addition to Verdun. Other municipalities are also well served. A good portion of requests for MAID are made due to psychiatric or psychological disorders, and not physical ones. We regularly offer palliative sedation to people who are tired and suffering to help them sleep and often, so that they do not wake up again.

MAID is another issue, it is not part of the continuum of palliative care. It is an essential and complementary addition to palliative care. That's the way that I see things.

[Luc Thériault, Bloc, Montcalm, QC]

I'm not sure that I've understood. Are you saying that when palliative care is good, there's no desire to request MAID?

[Dr. Geneviève Dechêne]

No, quite the contrary. I'm sorry, I must have not expressed myself clearly. When palliative care is good, approximately 96% of patients do not request MAID. I said 96%, not 100%.

[Luc Thériault, Bloc, Montcalm, QC]

In those cases, there is no request for MAID.

[Dr. Geneviève Dechêne]

Actually, those patients talked to us about it many times, and they said that they felt better and relieved in the end, and they had an acceptable quality of life until the end.

Three to four per cent of our patients receive medical assistance in dying. I'd like to add that those patients often decide in advance to receive MAiD before they have physical pain or shortness of breath, but they are experiencing significant psychological pain. Also, they absolutely need to control the decision regarding the day, the hour and the minute of their death, and we have to respect that.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Last, we'll have Mr. MacGregor. You have five minutes.

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

Thank you, Madam Chair.

Thank you to all of our witnesses for appearing today.

Mr. Hawkswell, I'd like to direct my questions to you if I may. It's good to see you join our committee today. I really did appreciate how your comments were focused on a patient-centred approach. We, as a committee, have previously had Dr. Valorie Masuda appear before us, who's one of my constituents. She's a palliative care physician and she has seen first-hand with her patients how psilocybin in a controlled environment has definitely relieved their anxiety, the existential dread they feel when they are approaching the end of their life, and has allowed them to focus on that part of their life with friends and family present and with a much more sound mind.

You mentioned the research from Johns Hopkins. I'm just reading their website. I'll quote it:

Research to date [demonstrates] safety of psilocybin in regulated spaces facilitated by medical [teams] over a series of guided sessions; and as a part of cognitive behavioural therapy, psilocybin helps in reducing anxiety in some cancer patients, and in facilitating even smoking cessation for some.

Can you add a little bit more to what that research is pointing towards, and later on would you be able to submit some of that research to this committee so that we can consider it as we're approaching our final report?

[Spencer Hawkswell]

I can absolutely submit some research and opinion pieces from the patients and doctors if you would like. I believe they're very helpful and outline more patient-centred cases in which both patients and health care professionals, as well as families, have been helped by this.

I will just add a bit more on the use of psilocybin and what we've seen in close to 100 treatments that our organization has helped facilitate with doctors such as Dr. Val Masuda.

Psilocybin, the compound, alone does not alleviate much of the end-of-life distress. It's commonly referred to as that, but it is the combination of anxiety, depression and hopelessness that a patient faces when they're told that they're going to die. Again, this does not affect every cancer patient, but some of the literature reviews we've done—which we will also try to include—show that about 2,800 Canadians every year fall into this category of treatment-resistant depression or anxiety due to an end-of-life diagnosis.

What the psilocybin does, coupled with psychotherapy, which is what you're referring to and what Johns Hopkins was referring to, when it is conducted with clinicians in a safe space—and that space can be the patient's home, where many of the treatments have been done—is to aid in the psychotherapeutic process. It allows people to let their guard down. In many cases, it allows the therapist to actually do the work that they need to do.

For many people the psychotherapeutic process is hindered by lies that people tell themselves and by fears. In many cases, the patients coming out of these experiences are reporting that they are no longer afraid of death or that they feel a oneness with the universe. It is essentially years of psychotherapy packed into a single session with the help of medicine.

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

Thank you.

I have limited time left. Psychedelics Canada is asking for three key things. They want more federal government research into this by the Canadian Institutes for Health Research; they want clear, effective and evidence-based regulations; and they want a pharmacist compounding psychedelic substances under Health Canada's special access program.

Can you add a little bit more to that and put it in the context of the barriers you have faced under current regulations? What kind of recommendations would you like to see this committee make in its final report so that we are making sure that end-of-life care truly is a patient-centred approach?

[The Joint Chair, Hon. Yonah Martin]

You have just under one minute.

[Spencer Hawkswell]

I'll be very quick, then, and will comment on the special access program and regulations.

First, the special access program, which was amended in January of this year to facilitate psilocybin use, is a complete and total failure. Eighteen patients have been granted access. Val Masuda, the doctor of one of your constituents, can attest to the fact that SAP was a failure. Health Canada is now telling us and many of the doctors and patients that they are to not use the SAP and to use clinical trials, which is wrong here.

We need regulations. We need medical regulations. Our organization has written those medical regulations and submitted them to the ministers of health. Those medical regulations fall right in line with the medical cannabis regulations, which, again, are based upon human rights. That's what we're looking for—the human right to try psilocybin, especially for those for whom it works.

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

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Now we'll go to our round of questions from the senators.

I will turn this over to my co-chair.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator Martin.

We'll begin with Senator Mégie.

Senator, you have the floor for three minutes.

[Marie-Françoise Mégie, Senator, Quebec (Rougemont), ISG]

Thank you, Mr. Chair.

My first question is for Dr. Dechêne.

Good morning, Dr. Dechêne.

[Dr. Geneviève Dechêne]

Good morning, Senator Mégie.

[Marie-Françoise Mégie]

The notes that we get, which are reports, articles and even legislation, refer to palliative care and end-of-life care. That can really confuse people who don't work in the field.

Could you please explain the difference between “palliative care”, because you talked about the final 12 months of life, and “end-of-life care”?

[Dr. Geneviève Dechêne]

That's a very good question. Thank you, Senator Mégie.

The Collège des médecins du Québec helped us draft the definition. It produced a document I was happy to help write, Medical Care in the Last Days of Life. In the last week of life, patients do not receive palliative care, they receive care for the last seven days of life.

Palliative care is all types of care given to someone with a guarded prognosis, who has an incurable terminal illness and is in agony. Take, for example, a heart failure patient. I challenge even the top cardiologists to determine the day and time of death of a patient with an enlarged heart. Death can come the next day or eight months after their checkup. These patients choke regularly. They need opiates to relieve their shortness of breath. That's what palliative care is. It's care often given in conjunction with acute care. Palliative care should not be seen as something that blocks and prevents acute medical care. I can give my heart failure patient diuretics to get rid of excess water, but also morphine to relieve their shortness of breath. So palliative care is provided over a long period of time, months, but rarely years. In the Western world, people rarely die of pneumonia. We die of chronic terminal illness.