Medical Assistance in Dying Committee on Oct. 18th, 2022

[Baroness Finlay of Llandaff]

Very rapidly, you have to differentiate generalist palliative care provision from specialist palliative care provision. We have just changed the law so that specialist palliative care and palliative care are core parts of NHS provisions. One person not getting the care they need is one too many, I would have to say. Really, the difference is between access to specialists and those who get general care.

When the generalist can't cope, the person should be referred to specialist palliative care. Specialist palliative care cannot look after everybody who's dying, but everybody who is facing the end of their life needs good care. Those skills are then transferable to other aspects of medical care for people with distress, for whatever reason, including those bereaved because they've lost somebody suddenly, or whatever. Those are transferable skills, and they must have standards that they're measured against.

[The Joint Chair, Hon. Yonah Martin]

Thank you, Baroness.

We'll go to Senator Dalphond.

Senator Dalphond, you have the floor for three minutes.

[Pierre Dalphond]

Thank you, Mr. Joint Chair.

My question will be for you, Dr. Henderson. You're so close. I understand from the previous witnesses—and I think Dr. Li mentioned it—that 82% or even more of those receiving MAID had previously received good palliative care. Would you agree with this or not?

[Dr. David Henderson]

No, I actually don't. We don't know that for sure—well, the thing we do know is that 18% to 20% of the people from that study, first off, didn't receive any palliative care. There were another 20% who received palliative care only in the last 14 days of life, and that's not enough time, especially if you're dealing with psychosocial suffering. You don't fix or remedy that in 14 days.

[Pierre Dalphond]

Based on your experience—you're not a MAID provider, but a palliative care provider—have many of your patients, after a certain moment, asked for MAID?

[Dr. David Henderson]

Oh, yes, for sure.

[Pierre Dalphond]

Would you dismiss their request or agree to the request?

[Dr. David Henderson]

We actually teach also. We never abandon the patient.

There was a comment made about having to choose between MAID and palliative care. If the person's receiving palliative care, they can continue to receive palliative care right up to the time they have MAID. We don't intend it ever to have to stop unless the patient does not want to continue with palliative care. It's always available.

We teach, and we taught for years and years before this became available, that when someone says they think life's not worth living, we start by exploring that. We inquire, “What do you mean by that?”, so they can say, “I don't feel I want to live anymore.” Then we talk about what the root cause of that is. That's one thing that is lacking in a lot of the assessments for MAID when palliative care is not involved. The assessment involves only whether they qualified for MAID; it doesn't ask what the root cause of someone's suffering is and how we can fix that.

[Pierre Dalphond]

You say that because you did some MAID assessments?

[Dr. David Henderson]

No, it's because I work with people who have done MAID assessments. I was actually involved in developing the policy and developed a tool to help people who didn't work in palliative care to be able to do assessments, only to be told that doing those would take too long.

[Pierre Dalphond]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you very much.

With that, the panel is coming to a close. I want to thank our witnesses this evening: Baroness Finlay, Dr. Henderson and Dr. Li.

Thank you for your forbearance with our slightly compressed schedule.

[The Joint Chair, Hon. Yonah Martin]

Do I have my three minutes?

[The Joint Chair, Hon. Yonah Martin]

I beg your pardon. That was my mistake. I forgot one of the senators, my own co-chair. I'm in trouble now.

[Voices]

Oh, oh!

[The Chair]

Please go ahead, Senator Martin. You have three minutes.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

My first question is for Dr. Henderson. You mentioned earlier in a response that we haven't had the proper checks and balances in place, so I want to ask how we can improve oversight and monitoring of MAID to ensure that Canadians are not choosing it because they lack access to the necessary resources needed to live, including palliative care. What is needed?

[Dr. David Henderson]

Again, I'm not the expert on this. This is such an important thing, and it's such a definitive thing. Somebody's life ends with this. I mean, there's not much more importance than that, so we need to make sure that we're doing this right. It's legal now, and it's something that is being used. We just need to make sure we're doing it right.

I think there needs to be an oversight body—and perhaps not even within the government—that has the ability to review cases. There also need to be some national guidelines around what cases you review. If somebody doesn't follow the guidelines, what are, clearly, the consequences for not following those so that physicians don't get surprised at the end of the day when in good faith they provided MAID, only to find out they did something wrong, and they have no idea what the consequences are going to be? Those things all need to be very much cleared up and very transparent so that everybody knows the game and what the rules are.

To me, there should be audits. I think you could flag high producers, basically. People who are doing a lot of cases probably should have more of their cases audited to make sure everything went well and was above board. Then there should be just random checks on other people providing the care. That's what happens already in health care for family physicians and all physicians. At different times, charts can be audited just to ensure that we're providing quality care, so if there's anything we should be making sure is done properly and above board, it's ending somebody's life on request.

[The Joint Chair, Hon. Yonah Martin]

Do I have time for one more quick question?

[The Joint Chair, Hon. Yonah Martin]

Yes, you have a minute.

[The Joint Chair, Hon. Yonah Martin]

Baroness Finlay, do medications used in palliative care alter a person's capacity to consent to something like MAID?

[Baroness Finlay of Llandaff]

They can do so, and we have to be really aware that morphine can make you distressed and that steroids can make you more emotionally labile.

When somebody says that they feel their life isn't worth living, you need to answer that with a question as to why, what's going on and what's happening. It may be that there is some medication there that is altering their capacity. It may be the cancer itself that's altering the capacity or the other disease they have. They may have a depression.

You have to explore it and diagnose the underlying cause. Then, when you've done that, you need to deal with the underlying causes of their distress. However, if you just respond at face value, then you'll never begin to understand the person and what they really need.

The danger is forgetting that autonomy is relational. We all interact. The way the doctor behaves towards the patient alters the way the patient receives their outcome. There's good evidence from Canada that dignity is enhanced by the way that care is given or is undermined by the way it isn't given.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

With that, we are now officially at the end of the panel.

I would like to, again, thank our witnesses. I think we all agree here that your views were made very clear this evening in this second panel. We very much appreciate your taking the time to be with us.

With that, I will officially adjourn this committee.