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

[Dr. José Pereira]

Yes, certainly.

A study of world rankings has been published recently. There was a large Economist study done and published in 2015. Canada stands at about 10th or 12th on the list overall, but we start dropping in certain areas. For example, in funding for private care resources, we've dropped down to the 20th spot, so there's room for improvement.

Many other jurisdictions, such as the United Kingdom and Australia, put a lot of effort into ensuring they have enough specialist palliative care services and specialist palliative care teams, and they also build up what we refer to as the primary part of care. In other words, all health care professionals caring for patients with cancer, heart diseases, lung diseases and renal diseases, etc., have those core skills—

[The Joint Chair, Hon. Yonah Martin]

Thank you.

[Dr. José Pereira]

—and in Canada, we still have a long way to go to ensure that is occurring.

[The Joint Chair, Hon. Yonah Martin]

Okay. Thank you very much.

Next we will have Monsieur Arseneault for five minutes.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Thank you, Madam Chair.

I thank the witnesses for being here, including those from the first panel, if they are still watching us. It has been really enlightening.

I will address you first, Dr. Roy. The data that we have in the annual reports on medical assistance in dying for the last three years is quite telling in terms of the proportion of people who request medical assistance in dying versus those who request palliative care. What was feared does not seem to be happening—that is, 82% or 83% of the people who requested medical assistance in dying were receiving palliative care. They decided to leave of their own free will, with medical assistance in dying. We also know from the same data that 89% of those who chose not to use palliative care had access to it.

You have been working in palliative care for 22 years. Can you tell us what explains why someone would want to receive medical assistance in dying without necessarily wanting to use palliative care?

[Dr. Louis Roy]

Thank you for that question, Mr. Arseneault.

In this case, I will put on my clinician hat. That stage of my career ended when I joined the Collège des médecins du Québec, but I still had a long career as a clinician. I have also worked extensively in palliative care, participated in the implementation of medical assistance in dying, and administered medical assistance in dying to many patients myself.

To answer your question, I can speak from my experience as a clinician in Quebec, particularly in Quebec City, where I was, among other things, head of palliative care at the university hospital. The vast majority of people, as you said based on your numbers, had access to palliative care when they requested medical assistance in dying. You really have to look at it as a continuum of care. When medical assistance in dying was implemented in Quebec, we put a lot of emphasis on the fact that palliative care must be present.

It should be remembered that legislation was passed in Quebec a number of years ago, so that palliative care would not be optional in institutions. All public institutions must have a program or plan to provide palliative care, which is not the case everywhere in Canada and which is completely different from what I had experienced some 15 years before the passing of that legislation. I had even been told by someone in an administrative position that my palliative care business was irrelevant to the mission of their institution—

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Dr. Roy, I'm sorry to interrupt, but I really don't have much time.

What makes a person choose to obtain medical assistance in dying bypassing palliative care?

[Dr. Louis Roy]

In my experience, most people who directly request medical assistance in dying have already come a long way and are at a stage where palliative care is not the outcome they envision. This can particularly affect people who have a neurodegenerative disease and who see themselves declining. I'm thinking of amyotrophic lateral sclerosis, ALS, also known as Lou Gehrig's disease, among others. They receive care, but it cannot necessarily be called palliative care. Although they have support, these people have chosen a critical juncture past which they do not want to receive intensive palliative care, but rather receive medical assistance in dying.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Thank you very much.

Dr. Pereira, could you tell me very quickly if you agree with what Dr. Roy just said about palliative care and medical aid in dying being part of a continuum of health care?

[Dr. José Pereira]

Madam Chair, I would disagree. With regard to the 80% access, I think we need to stop and look more closely at that number. We don't know what the quality of the palliative care is there. Often it is very late. Often people have suffered for months and months, leading to suffering that then reaches a point where palliative care is finally adjacent.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Have you read and understood the Supreme Court of Canada's Carter decision, which led to the availability of medical assistance in dying in Canada?

[Dr. José Pereira]

I have read it through, and I was actually part of it, so I am very much aware of it. I think it's important—

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Dr. Pereira, would you agree that the patient is at the centre of the decision in this case?

[The Joint Chair, Hon. Yonah Martin]

Answer very briefly, Dr. Pereira.

[Dr. José Pereira]

Madam Chair, I think it's important to say that autonomy and the patient being at the centre of the care have always been a foundational piece of palliative care.

I think we need to ask ourselves whether there are limitations as well. Are there things that we are missing? Are there opportunities that we are missing?

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Okay. My time is up.

Thank you all.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

Next, we'll have Mr. Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you, Madam Chair.

I will go to Dr. Roy.

During your opening remarks, you talked to us about harmonizing legislation. So I assume you were referring to the harmonization of Bill C-7 and the Quebec bill, the Act respecting end-of-life care.

You talked about the concepts of illness, disease and disability. It seems to me that the Criminal Code and Bill C-7 are pretty clear. What is the problem that makes you talk about harmonizing legislation?

[Dr. Louis Roy]

The problem is that, in the Quebec bill, the notion of disability is not recognized as a possibility for requesting medical assistance in dying. In French, a distinction seems to be made between an individual who suffers from a progressive disease and a person who has a physical disability.

The simplest example of a physical disability is the case of a person who becomes quadriplegic as a result of a car accident and who must receive constant care from everyone, both for hygiene and nutrition. However, this is not a progressive issue.

In medical terms, as currently worded, the Quebec bill considers that this person suffers from a disability, not a disease that will progress, which prevents them from qualifying to receive medical assistance in dying. If the individual wants to receive it, they must “find a disease”, if you will pardon the expression, that will be progressive. It's really a matter of determining whether another condition is present that causes a health condition to progress.

[Luc Thériault, Bloc, Montcalm, QC]

In short, it is not at all a case like Truchon and Gladu where, in the end, the disability is induced not by an accident, but by a progressive disease.

[Dr. Louis Roy]

Yes, exactly.

[Luc Thériault, Bloc, Montcalm, QC]

Okay.

You talked about mental illness and mental disorders. We've just finished this segment, but I'm going to take advantage of your time with the committee. Have you read the expert panel's report?

[Dr. Louis Roy]

Yes.

[Luc Thériault, Bloc, Montcalm, QC]

The report states that the assessment should be done by a psychiatrist who is independent of the treatment team. Do you think this is realistic, given the resource situation on the ground in Quebec?

[Dr. Louis Roy]

That's a great question.

I agree with you, the resource situation means that there is already some difficulty in accessing mental health care. The difficulty that stands out is making sure an independent assessment is obtained.

Since the therapist may have been meeting with a patient for several years, the therapeutic relationship could be tinged with certain elements. Having an independent third party confirm the opinion of the treating physician appears to be a source of safety to ensure that one is not moving a little too quickly or missing something important.