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

[Luc Thériault, Bloc, Montcalm, QC]

The question is whether we will be ready to implement the legislation by March 2023. Indeed, the legislation currently contains a sunset provision.

Do you think we will be able to move forward? That was more my question.

[Dr. Louis Roy]

I am not an expert on the whole issue of access to mental health care, but I believe that, if something is to be implemented, the system needs to be able to take the necessary steps to allow access and accessibility.

[Luc Thériault, Bloc, Montcalm, QC]

Okay.

The report also talks about the idea of implementing a prospective oversight process. Yet that oversight is retrospective in the case of the Commission on end-of-life care in Quebec.

In this case, oversight would be prospective. This implies that, following the entire process, a step would be added. Mandatorily, not as needed, a committee would decide whether or not the patient and the assessment have addressed all the requirements.

Do you think this plan is realistic and can be implemented quickly?

[Dr. Louis Roy]

I will express my personal opinion, which is not necessarily that of the Collège des médecins du Québec. The implementation of such a measure is going to pose some challenges. The application of a prospective measure should, in my opinion, be reserved for contentious, less clear or specific cases.

Then it will be necessary to clearly define within the legislation what will need to be specified.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Thank you.

Next we'll have Mr. MacGregor. You have five minutes.

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

Thank you, Madam Co-Chair.

Dr. Pereira, I'd like to start with you. In the previous panel, we had a witness from TheraPsil who was talking about the research that's going on in Johns Hopkins University into psilocybin therapy used in a very controlled environment with cognitive behavioural therapy. One of my own constituents, palliative care physician Dr. Valorie Masuda, has been granted access to this through special exemptions from Health Canada, and she has reported remarkable success in helping patients who are in palliative care overcome their anxiety.

Do you have any thoughts to offer on this research?

There have been calls not only for additional funding into the research, but also to tackle Health Canada's overly complicated and restrictive rules. I want you to answer this in the theme of a patient-centred approach, if we are trying to help patients at the end of their life in palliative care meet their end in a safe and controlled way such that they are not filled with anxiety.

Do you have any thoughts on this?

[Dr. José Pereira]

Mr. Chair, I'd like to thank the member for that excellent question.

I think what that illustrates is that contrary to what a previous panellist said, which was that there are no solutions or approaches to addressing existential distress, there are, and there are growing numbers of them. One of them in this class of medications is psilocybin.

I've been monitoring the literature coming out, and the results are quite amazing for many persons. They get significant relief from existential suffering as a result of that therapy. Many people as well benefit from approaches such as dignity-conserving care developed by Professor Chochinov.

I would argue that yes, there are approaches to address existential distress. I've seen that in my own practice with my own teams, and it makes a difference, so I think we have to be careful about making assertions that there are no treatments or approaches. Obviously there's not the panacea yet, but we are stretching out. We're improving every year on how we can address these needs.

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

Thank you for that.

To the Champlain Regional MAID Network, am I correct here that your areas of service include not only the city of Ottawa, but also Renfrew County; Stormont, Dundas and Glengarry; Prescott and Russell; and north Lanark?

Is that correct? I see it is.

We've heard comments about the challenges that exist for rural Canadians in accessing service. Can you add anything to what you've heard, based on your own personal experience, and compare patients who live in the city of Ottawa to Canadians who live in those more rural areas that your network also serves?

[Mike Kekewich]

Yes, certainly there are some differences in terms of the experience of living in smaller communities and the types of institutions that exist in those communities.

Not that there were many things that were positive about the pandemic, but thankfully, one thing was that virtual care became a very normal modality for providing linkages between patients and providers. I think we were able to mitigate more effectively some of those disparities, to the extent that they exist, by pairing people with services that they needed.

I wouldn't say it's perfect by any stretch of the imagination. I also don't know that I would say that even all rural communities are the same in terms of their access. I think we're making some progress, though. I appreciate the question.

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

Thank you.

Dr. Pereira, I'd like to return to you for my last minute. You talked about how not enough physicians are getting palliative care training. In your observation, how are our medical schools meeting this challenge, especially when you fast-forward 10 or 20 years and look at the demographics of Canadian society? How are the colleges of physicians and surgeons meeting this challenge?

Also, do you have any thoughts about specific regions of Canada that may have a higher-than-average elderly population? I've spoken to members of the provincial legislature in Nova Scotia. They have a very high elderly population, and they don't think the current funding model adequately looks after their particular needs as a province.

[The Joint Chair, Hon. Yonah Martin]

Please be very brief, Dr. Pereira.

[Dr. José Pereira]

All right.

The authorities that oversee the medical schools and residency programs have incorporated palliative care as a core competency, but we struggle as educators to get palliative care content inside the curriculum to get our rotations done. There are a number of barriers, and one of them is insufficient faculty. There absolutely is a lack of palliative care specialists.

I know the Champlain region very well. I worked there for a few years. In Petawawa, for example, the family health team trained up the whole team to provide a palliative care approach, and it's made a very big difference, but there are still many areas across the country—and you've highlighted some of those rural areas—where there aren't enough resources.

I've also helped in New Brunswick, trying to build the palliative care capacity there—

[The Joint Chair, Hon. Yonah Martin]

Thank you, Dr. Pereira.

It's now over to you, Mr. Co-Chair.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Senator Martin.

We'll now proceed with the Senate questions, beginning with Senator Mégie.

Senator Mégie, you have the floor for three minutes.

[Marie-Françoise Mégie]

Thank you, Mr. Chair.

I am happy to be taking the floor after my colleague Mr. MacGregor because his question is the same as one of mine.

It is increasingly noticeable that the public and all professionals are receiving a lot of information about the implementation of the medical assistance in dying program. However, when I was practising medicine, I noticed that the population knew nothing about palliative care. People who were offered palliative care were resistant to it.

Today, palliative care is still contrasted with medical assistance in dying. What could be done to educate the public about what palliative care is, as is done for medical assistance in dying?

How could provincial colleges of physicians better educate professionals about palliative care, so that they can advise people about either option when the time comes?

Dr. Roy, has the Collège des médecins du Québec ever thought about that?

[Dr. Louis Roy]

Thank you, Senator Mégie.

Yes, a lot of thought has been put into that.

On that note, I would say that the problem of information about access to palliative care goes back a long way. It also comes from the fear of talking about death, of talking about topics that are not easy.

I think the shortcut to medical assistance in dying was taken not because it was necessarily easier to talk about it, in terms of public information, but because it was something new for the press and the media. There was something new to put out there, whereas when you want to talk about palliative care, you have all the problems of what you are going to say, who you are going to say it to, and how you are going to say it.

On the public side, we really need some very targeted, but also well-organized, press campaign elements to explain to people what palliative care is.

I noticed in my long experience in palliative care that the best ambassadors to talk about it well are the families and loved ones of people who have received it. They are the best people to do it. They can say that their mother or aunt received palliative care, that it was a positive experience, and that this person received care, comfort, and relief.

On the physician side, Dr. Pereira talked about this. Medical schools are getting into it, but they definitely need to continue to [technical difficulties]. Obviously, all of this fits into an increasingly heavy curriculum in medicine where it is difficult to tell future medical students that they are going to have to add one or two years of study to successfully cover everything. We need to successfully condense everything even more.

Obviously, our medical students need to be confronted with the fact that everyone is going to die someday, but they also need to be exposed to palliative care during their training.

[The Joint Chair, Liberal, Marc Garneau]

Thank you, senator.

Please proceed, Senator Kutcher.

[Stanley Kutcher]

Thank you, Chair.

Thank you to the witnesses.

Before I ask my questions, I would ask the chair if he could request that Dr. Pereira provide this committee with a written report supporting his opinion that, one, people are being provided MAID instead of access to palliative care when they want palliative care; two, the data that shows that people who are receiving MAID have received suboptimal palliative care; and three, that resources are being diverted from palliative care to MAID provisions outside the usual ongoing annual reallocation of resources in the health care system.

I have questions for both Dr. Kekewich and Dr. Roy.

Dr. Kekewich, you raised a concern about the possibility of a real shortfall in the health care workforce that can provide MAID and palliative care. Both are very important. How can that human resource problem be addressed by the federal government? Can you think about whether targeted health care transfer funds might be part of that solution?

Dr. Roy, would regulatory bodies have within their jurisdiction the ability to require that MAID providers must have completed a national training program in MAID assessment and delivery?

Go ahead, Dr. Kekewich.

[Mike Kekewich]

That's an excellent question. I think it's something we've struggled with, quite frankly, in terms of what the strategies look like.

I think one of the interesting things about MAID is that most clinicians who are providing MAID are not doing it full time; they are doing it in addition to other work that they're committed to, so it has to be rewarding for them. It has to be meaningful for them.

I think certainly the volumes are one thing, in terms of their increase over time, and the complexity may also increase over time, as new patient populations start requesting it. I think there have been some innovative attempts to develop MAID coordination services that really support clinicians. It can be very administratively burdensome to have a large caseload of patients, for example.

I think focusing on those types of strategies, so that there's a team that's supporting patients—not just the clinician on their own, but a team of nurses, social workers and perhaps other specialists who could be available to give support—would be helpful.

[Stanley Kutcher]

Thank you for that.

Dr. Roy, please go ahead.

[Dr. Louis Roy]

Thank you for your question.

If you don't mind, I will continue in French to make sure that I make my [Technical difficulty—Editor] more clearly.

With regard to palliative care, obviously, we have come a long way, as there was initially no training. Initiatives were organized locally all over. At the national level, a working group is setting up a training program on medical assistance in dying for physicians and nurse practitioners. This program, whose modules I am helping review, is expected to be in place by the spring of 2023. In terms of training physicians and nurses in medical assistance in dying, I think the pieces are gradually falling into place. It should have been done before, but at the very least, work is being done.

One thing remains to be done and remains a very worthwhile element to me. In my field, very few physicians are opposed to medical assistance in dying. A lot of physicians say that they don't feel capable of administering it, but they understand their patient very well and so they will redirect them to someone who has the training and feels physically, psychologically, and morally ready to do it. So there is that dichotomy, but overall I would say that—

[The Joint Chair, Liberal, Marc Garneau]

Thank you, Dr. Roy.

Senator Dalphond, the floor is yours.

[Pierre Dalphond]

Thank you, Mr. Chair.

Dr. Kekewich, you have done a lot of analysis and research on the data, which is evidence-based and available. Is there any data indicating that people chose medical assistance in dying because of the poor quality of palliative care they were receiving?

I am asking this question because you said that 80% of the people who have requested medical assistance in dying were already receiving palliative care.

[Mike Kekewich]

I have not seen anything to reflect that specific concern. I think I would agree to some extent with Dr. Pereira that there are limitations in terms of the data, and I believe that Health Canada is going to be collecting more specific data on palliative care involvement to help inform these types of discussions.

I'm not aware of any reports that support that claim, but the reality also is that it's not the case that 100% of patients receive palliative care, right? I think it goes back to understanding what adequate access to palliative care looks like.

[Pierre Dalphond]

My time is limited, so I'm going to ask you my second question. This one will be more related to ethics, since you are also an expert in that area. I understand that the whole issue of medical assistance in dying and that of continuous palliative sedation raise ethical questions. We see that these are accentuated when it comes to medical assistance in dying for mental disorders.

Do you think these justifications are admissible, given the vulnerability of these individuals, and how can they be countered?