Evidence of meeting #21 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 disease.

A video is available from Parliament.

On the agenda

MPs speaking

Also speaking

Julie Campbell  Nurse Practitioner, As an Individual
Derek Ross  Executive Director, Christian Legal Fellowship
Joint Chair  Hon. Yonah Martin (Senator, British Columbia, C)
Nathalie Zan  Doctor, As an Individual
Marie-Françoise Mégie  Senator, Quebec (Rougemont), ISG
Pierre Dalphond  Senator, Quebec (De Lorimier), PSG
Pamela Wallin  Senator, Saskatchewan, CSG
Serge Gauthier  Emeritus Professor, As an Individual
Nancy Guillemette  Member for Roberval, Government of Quebec
Sandy Buchman  Chair and Medical Director, Freeman Centre for the Advancement of Palliative Care, North York General Hospital, and Past President, Canadian Medical Association, As an Individual

9:05 a.m.

Dr. Nathalie Zan Doctor, As an Individual

Hello. I hear you very well.

Madam Chair and honourable members of the committee, I have a written statement, which I prefer to read. It will be more comfortable. I will be addressing you in French.

My sincere thanks for inviting me to appear before the Special Joint Committee on Medical Assistance in Dying. This is a subject that is of particular interest to me. The objective of this testimony is to tell you about the challenges I see when it comes to access to the continuum of palliative care, including medical assistance in dying.

I have been a family physician in Quebec since 1993. My field of practice was very general in the beginning, but since 2009 I have worked mainly in geriatrics. I have had the opportunity to practise family medicine and geriatric medicine in virtually every setting, in all types of general medicine practices. I have also been a medical manager for several years.

Caring for patients who have irreversible and incurable diseases is an important part of my everyday work, and I have administered medical assistance in dying several times over the last few years, so I want to tell you about my experience.

The demographic changes we are experiencing, that become more apparent every day, mean that the need for palliative care and requests for medical assistance in dying are rising exponentially. Despite the efforts made to develop these kinds of care, there are still limits on access to them.

I observe that each person's experience can be very different, for a variety of reasons. Some examples come to mind.

First, there a person who is in hospital and needs palliative care and is waiting for a single room, to which they are entitled. In the health institution where they are, there are not enough single rooms, and the person dies in a two-person room or in a ward. Too many people are still dying in the less than optimal environment of our dilapidated institutions that offer poor accommodation for both the people being cared for and their families.

Second, people at the end of life are often waiting for a bed in the palliative care unit, but the number of beds is limited. Some people receive a bed only at the very end of the course of their disease. Often, they are unconscious when they are transferred there; sometimes, they die without a bed being found for them.

Third, a person suffering from a non-cancerous chronic disease who requires specific palliative care may have more trouble accessing that care, given the limited number of beds in palliative care units.

Fourth, a patient living alone at home who is waiting for palliative home care services to be arranged may have to attend at the emergency room. Given the rising number of seniors who are living alone, this problem may arise more often.

Fifth, one of the admission criteria for a bed in a palliative care unit is that the person have less than three months to live. Individuals with a serious loss of autonomy with more than three months to live are often directed to the CHSLDs, regardless of their age and diagnosis. A person then admitted to a CHSLD is not in the right place to get the best palliative care. As well, they are unfortunately occupying a bed that is ordinarily reserved for seniors with very different needs, including specific palliative care. As well, some of these people die in less than three months without receiving optimal palliative care, unfortunately.

Sixth, some people who request medical assistance in dying have their access limited to certain palliative care beds in institutions that do not offer this type of care. Some of these people die without having access to optimal palliative care.

Seventh, some patients admitted to a palliative care institution have to change institutions in order to receive medical assistance in dying, since it is not offered in the institution where they are at the time.

Eighth, there is the issue relating to respect for the wishes of people who become incapable.

I believe we have to examine the level of care and the quality of the care offered and the services to be developed for the continuum of palliative care, which includes medical assistance in dying. The present shortage that affects every interdisciplinary professional team also makes this examination necessary.

I would stress that we are very fortunate to live in a society that allows and encourages the expansion of the available palliative care. In my area of practice, the east end of Montreal Island, the demand for medical assistance in dying is rising steadily. I am sure that this is the case everywhere in Canada.

Every day, patients ask me about medical assistance in dying and palliative care. Being able to choose care that is appropriate for their needs gives them reassurance. However, they are still worried about their wishes being respected and about access to their choice. Certainly, we have to continue working on educating our professionals and raising their awareness.

You and I do not know in advance what care we are going to choose in an end-of-life situation, which is where we will all inevitably find ourselves. My wish for you all is that we be able to be accommodated and that our ultimate and deeply personal choice be respected, and that we have access to all the care we need when the time comes.

Personally—

9:10 a.m.

The Joint Chair Hon. Yonah Martin

I'm sorry, Dr. Zan, but we have gone beyond five minutes. Thank you very much for your testimony.

9:10 a.m.

Doctor, As an Individual

9:10 a.m.

The Joint Chair Hon. Yonah Martin

We will return to our questions.

Next we have Mr. Thériault for five minutes.

October 21st, 2022 / 9:10 a.m.

Bloc

Luc Thériault Bloc Montcalm, QC

Thank you, Madam Chair.

My first questions will be for Dr. Zan.

Some people tell us there is no choice at present. You have described access to palliative care. Some people say the reason people request medical assistance in dying is that they do not have access to palliative care. Is that also your opinion?

9:15 a.m.

Doctor, As an Individual

Dr. Nathalie Zan

No. These are two totally different things. Obviously, there is insufficient access to palliative care, but that is not the reason why people request medical assistance in dying. I think both must be equally accessible. Medical assistance in dying is not an alternative to palliative care.

9:15 a.m.

Bloc

Luc Thériault Bloc Montcalm, QC

You said that all patients in the terminal phase, that is, who have less than three months to live, have trouble getting access to care. You also added something that threw me: someone who went to the hospital and said they wanted medical assistance in dying would be denied access to the palliative care unit. They would not have access because they had chosen medical assistance in dying.

9:15 a.m.

Doctor, As an Individual

Dr. Nathalie Zan

It think it depends on where the person is.

9:15 a.m.

Bloc

Luc Thériault Bloc Montcalm, QC

We are not talking just about hospitals. You say that someone who requests medical assistance in dying has to be transferred elsewhere when the institution where they are, for example a home, does not practise it, or when no one agrees to provide it.

9:15 a.m.

Doctor, As an Individual

Dr. Nathalie Zan

It can happen. In some institutions, there is no problem, because there is a continuum of care. However, there are cases where a person might be admitted to a palliative care unit in an institution that does not offer access to medical assistance in dying. That person would then have to go somewhere else to receive the care they want. The reverse is also true. It can happen. It is not the case everywhere, but it happens.

9:15 a.m.

Bloc

Luc Thériault Bloc Montcalm, QC

Some people say that palliative care covers much more than the end-of-life care phase. The Quebec statute is called the Act respecting end-of-life care. Obviously, as you said, palliative care is part of end-of-life care. What Quebec has done, with its law, is decide that a request for medical assistance in dying could be made as part of end-of-life care and must be accepted. The title of the law is not about medical assistance in dying; it is the Act respecting end-of-life care. So a continuum of care is offered that includes medical assistance in dying. If I am not mistaken, palliative care involves the totality of supportive care approaching death. A patient could therefore calmly and confidently opt for medical assistance in dying. As Ms. Campbell said earlier, medical assistance in dying must not be regarded as a failure of palliative care. The two principles must not be seen as conflicting. Is that your opinion?

9:15 a.m.

Doctor, As an Individual

Dr. Nathalie Zan

As we approach death, we might be satisfied with palliative care alone, or we might find ourselves in a situation where our suffering is too intense, in spite of that palliative care. Suffering can sometimes be absolutely intolerable. That is the real reason for having access to medical assistance in dying. It is used when needed. The option is there. Some patients may be getting along perfectly normally in palliative care and not expect to request medical assistance in dying, but given the deterioration in their condition, they decide to choose that option.

9:15 a.m.

Bloc

Luc Thériault Bloc Montcalm, QC

In palliative care and end-of-life care, pain control methods can bring about death in the long term. The patient will die not necessarily of complications associated with their cancer, for example, but rather of a heart attack caused by a last dose of pain relief medication. Because there is no resuscitation protocol, death then occurs.

Does this mean that we could say that palliative care is an action that leads more slowly, bit by bit, to death?

9:15 a.m.

The Joint Chair Hon. Yonah Martin

Be very brief, Dr. Zan.

9:15 a.m.

Doctor, As an Individual

Dr. Nathalie Zan

Yes, the disease can be the cause of death, but there are also dehydration and withholding food. The important thing is to relieve all this suffering. The objective of palliative care is to relieve the suffering associated with the process of dying.

9:15 a.m.

The Joint Chair Hon. Yonah Martin

Thank you.

Next we will have Mr. MacGregor.

You have the floor for five minutes.

9:15 a.m.

NDP

Alistair MacGregor NDP Cowichan—Malahat—Langford, BC

Thank you very much, Madam Chair, and thank you to all our witnesses for appearing before the committee.

Mr. Ross, I'd like to start with you. I think in your opening statement you underlined the complex relationship between the courts and Parliament.

Throughout our study, section 7 charter rights have come up frequently, but mostly in the case of people having the right to determine what kind of care they want and what kind of decisions they want over their own body. I actually found it interesting that you brought it up from a different perspective, underlining the first part of section 7, the right to life, and that this might be compromised because someone is not getting the full range of access to services, especially in palliative care.

To your knowledge, is there any individual or group of lawyers in Canada bringing a charter challenge from that perspective at this moment?

9:20 a.m.

Executive Director, Christian Legal Fellowship

Derek Ross

I believe there was a statement of claim issued by Roger Foley. I would have to go back and check where that litigation currently stands.

At this point, this issue hasn't been explicitly addressed by the courts in a written decision, but we do feel there are charter issues engaged here. Just to play that out, you can look at some of what the Supreme Court of Canada has said about the right to life. In Chaoulli, the court said the right to life is engaged where evidence shows that the “lack of timely health care can result in death”. In that case, the court also said, “delays in obtaining medical treatment which affect patients physically and psychologically trigger the protection of s. 7”, which is for security of the person. In Carter, the court said, “The right to life is engaged where the law or state action imposes...an increased risk of death on a person, either directly or indirectly.”

If we have a regime where certain basic health care supports are needed by a patient but are not available, where death is effectively being offered as the only accessible solution and where the government has not acted as it should in securing adequate supports that would otherwise lead a person not to seek death, then I think section 7 is engaged.

9:20 a.m.

NDP

Alistair MacGregor NDP Cowichan—Malahat—Langford, BC

I'm sorry to interrupt, but my time is running out. I do want to continue with you, though.

You were talking about the legal distinction between medical assistance in dying and palliative care. In actual medical settings, we have patients who are often in palliative care and make the decision that they want to transition to medical assistance in dying. Often it's happening in the same place. While I agree that you have the legal distinction, practically it's often happening in the same place. For lack of better purposes, it is a part of continuum of care in the practical setting.

We just heard from Dr. Zan that some patients, when they make a choice to transition from palliative care to MAID, have had to transition to a different facility because services aren't offered. In your opinion, how do we balance the rights of the institution providing the care with the rights of the patient to have that continuum of care and not have the end of life interrupted in such a severe way?

Let's say you've gone through palliative care and feel like the treatments aren't working anymore, and you don't feel like you need to stay on this earth anymore but your decision to go into medical assistance in dying means you're going to be packed up into an ambulance and transported to a different facility. How do we protect your rights versus the kind of care you're receiving?

9:20 a.m.

Executive Director, Christian Legal Fellowship

Derek Ross

These are all questions that need to be looked at. At the end of the day, even though both MAID and palliative care may be provided to the same patient, I think it is important that a person who is seeking MAID continues to be offered palliative care. That's absolutely crucial. We shouldn't look at it as a binary where either you choose palliative care or you choose MAID, and if you choose MAID there's no palliative care available to you. I think Dr. Zan's testimony on that point—that this is still emphasized—is really important. Yes, there is a legal distinction, but that doesn't mean someone seeking MAID should not be offered all of these palliative care supports.

I think the challenge though—even in the example you provided—is that often palliative care is only being provided at a very late stage, even after a point that a person is seeking MAID or in the final two weeks of their life. As we've seen in some of the Health Canada reports, the evidence that's been heard is that it's not soon enough. Giving only two weeks of palliative care is not going to begin to address some of these deeper issues.

Even before we get to the dilemma you've just identified, it's important that there be early interventions, early referrals and early awareness of palliative care so that it's being provided over a long term. Then we don't get to this point where someone is in the possible dilemma of feeling like they only have a couple weeks of palliative care and then have to be transferred.

I think it's really something that requires a proactive, pre-emptive approach. It has to take place at a very high societal level for us to be prioritizing it.

9:25 a.m.

The Joint Chair Hon. Yonah Martin

I was listening to the answer. We did go a bit over the five minutes, but thank you.

9:25 a.m.

NDP

Alistair MacGregor NDP Cowichan—Malahat—Langford, BC

Thank you.

9:25 a.m.

The Joint Chair Hon. Yonah Martin

I'm going to now turn it over to my co-chair and we will have questions from the senators.

9:25 a.m.

Liberal

The Joint Chair Liberal Marc Garneau

Thank you very much, Senator Martin.

We'll now have senators' questions, beginning with Senator Mégie for the next three minutes.

9:25 a.m.

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

Thank you, Mr. Chair.

I want to thank the witnesses for being with us today.

My first question is for Ms. Campbell.

In your opening remarks, you talked about the fact that some people are less likely to be referred for palliative care. Can you give us some examples where, given the patient's health, the doctors or health professionals are less likely to refer patients for palliative care?