Evidence of meeting #22 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 request.
A video is available from Parliament.
Bloc
The Joint Vice-Chair Hon. Marie-Françoise Mégie
Someone else may have an opportunity to come back to it.
I now give the floor to Mr. MacGregor for five minutes.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you.
I'll direct my questions to Dr. Pageau.
In your opening remarks, you hit on two items.
First, there can be problems with errors in interpreting the written instructions from a patient, especially when that patient has lost capacity to help someone interpret what they originally meant. You also mentioned there is a stigma associated with dementia. I want to ask you about those two points, because we've had previous witnesses who said there ought to be a requirement for objectively assessable criteria, which can be very clearly understood: for example, “When I reach a certain stage in dementia, this is what I would like to happen.”
I understand that there is a stigma out there against Alzheimer's. It's not very clearly understood. However, to take a different side, is it not paternalistic of us to assess someone's feelings about dementia, especially if that person once lived with a family member who had dementia, understands the disease intimately, and also understands what is coming their way?
I'd like to hear your feedback on those two points, please.
Geriatrician and Researcher, As an Individual
Yes, it's a matter of interpretation. The third party must initiate the request, as was previously mentioned. The physician must then determine whether it's valid and will then examine what the patient has written.
The cited criteria are often incontinence and inability to recognize family. However, those criteria may emerge early in the development of the dementia, but the person may nevertheless be happy. Some people don't want to use the term "dementia" because they consider it so pejorative. That shows you how much "dementiaphobia" there is in society.
My colleague mentioned the discomfort that may be felt at the idea of suggesting medical assistance in dying and the fact that we sometimes prefer to wait for the patient to request it. When one of my patients has an infection, I don't wait for him to ask me for antibiotics; I know that they're the appropriate treatment and therefore suggest it. The patient may then decide whether to accept it. When I know that a treatment is right, I propose it without waiting to be asked.
It's interesting to note this discomfort over medical assistance in dying. If physicians wait for patients to request it from them, that may be because they aren't comfortable proposing it. The discomfort may also be exacerbated by "dementiaphobia". The word "dementia" is so frightening that some people in the United States have decided to call it a "major neurocognitive disorder". The stigmatization associated with dementia is known and present.
When an individual reaches an advanced stage of dementia and the medical team attempts to determine whether the patient's inability to recognize his or her loved ones constitutes sufficient suffering to warrant medical assistance in dying, they may potentially be relying on "dementiaphobic" criteria.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you.
I'd like to turn my next question to Professor Iftene.
Thank you for sharing your perspective on the experience inmates have in our federal prisons, which I don't think has often been talked about. Over the summer, I got to visit two of our federal institutions in British Columbia. That was a big learning experience for me.
You centred a lot of your remarks on the substandard medical care available to inmates in federal institutions. For patients who might be in a maximum-security prison, serving time for a very serious crime—we're talking about life imprisonment—when those patients start exhibiting symptoms of dementia and are obviously unable to comply with a regular prison routine, or even interactions with guards or other inmates, how do they progress, generally? Do they go to a lower-security facility?
Could you talk a bit about inmates who are diagnosed with those neurocognitive disorders and start exhibiting some of those symptoms?
October 25th, 2022 / 7:05 p.m.
Associate Professor, Schulich School of Law, Dalhousie University, As an Individual
It's very difficult. Many times, in prisons, dementia and other major cognitive impairments are misdiagnosed, because first responders tend to be officers. They obviously do not have any expertise in this. Even the prison physician, who might have access to seeing these people, does not have the expertise necessary to diagnose these issues.
What we end up seeing, many times, is people who may have had dementia for a number of years, but who were misdiagnosed as having alcohol withdrawal. That's a very common thing we see, or having behavioural issues, misbehaving and being sent into various [Inaudible—Editor]. Now it's structured intervention units, but it used to be solitary confinement, or other things like that.
In fact, I've seen people with dementia moved from minimum-security institutions, because they were serving life, not because they're—
The Joint Vice-Chair Hon. Marie-Françoise Mégie
I apologize for cutting you off, but that's all the available time you have.
I now turn the chair over to Mr. Garneau.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Madam Chair.
We will now go to questions from the senators.
I give the floor to Senator Dalphond, who has three minutes.
Senator Pierre Dalphond
Thank you.
My questions are for Dr. Lussier.
As I understand it, in your view, if we adopt a system that permits advance directives, a diagnosis must be made and an incurable disease must exist. There has to be a finding.
Geriatric Physician, As an Individual
Yes.
Incidentally, I'd like to correct what you said, if I may. I prefer to say "advance requests" instead of "advance directives". It's an important distinction.
Pierre Dalphond
You're right: it's an advance request.
You discussed what happens when someone makes an advance request. The medical act will occur later. End-of-life care will be administered when the person no longer has the capacity to consent.
Right now, as a result of the amendments we've made, can people suffering from an incurable disease and whose death is imminent receive medical assistance in dying, even if they no longer have the capacity to consent to it, whereas they had that capacity at the time of the request? It would then be administered to them all the same. However, it wouldn't be possible to administer assistance to them if they showed signs of resistance. Is that what you'd recommend should be applied in response to the advance request? The moment a patient exhibited resistance, assistance in dying would not be administered.
Geriatric Physician, As an Individual
It's much more complicated in an advance request case. Patients who have cognitive disorders often resist everything. They may object to baths, getting dressed or brushing their teeth. In that case, I'm not sure resistance to treatment can be interpreted as a refusal of treatment. The question is far more complex in cases where individuals have cognitive problems.
I think we have to try to find a compromise between administering that care by force to a person who demonstrates physical refusal and cancelling the request that person has made. A compromise may be possible.
When patients make an advance request, they could specify in advance that they want the care to be administered even in the event of refusal, or that they prefer that the care not be administered to them in the event of refusal. I believe that could be a compromise. This dilemma could be resolved by the patients when they make their advance requests.
Pierre Dalphond
Right now, under the path one system, you immediately stop the process if there's resistance.
Geriatric Physician, As an Individual
Yes. However, that's not the same thing. People who are reaching the end of their lives and who lose their capacity are often unconscious. Resistance is less frequent. The person will be unconscious and therefore won't resist. That person won't be aware of his or her environment. It's not at all the same thing with persons…
The Joint Vice-Chair Hon. Marie-Françoise Mégie
Thank you, Dr. Lussier. I apologize for cutting you off. We have only three minutes.
Liberal
The Joint Vice-Chair Hon. Marie-Françoise Mégie
My question is for Dr. Pageau.
You mentioned an error made by the person completing the MAID request form. It seemed to me that it was the person who made the request but that the form was completed by a health professional assisting or accompanying the patient. What kind of error do you think that was?
Geriatrician and Researcher, As an Individual
It's the error of misguided autonomy. There has to be autonomy.
I can say at I want to buy a desert island in 10 years and wind up alone in a house, but, in the end, I have a large family and friends. Will I really want to live out my life alone on a desert island?
Perhaps my example's somewhat ridiculous, but we don't know what the future holds for us. Can we really anticipate dementia and the kinds of symptoms and psychological behaviours associated with it? People who think they can should provide some compelling evidence to confirm it. We don't know the future when a diagnosis is made. We don't know when the dementia will be advanced.
The Joint Vice-Chair Hon. Marie-Françoise Mégie
Thank you.
My second question is for Dr. Lussier.
With respect to safeguards, some witnesses have told us that, if someone makes a request for medical assistance in dying at some point in his or her life, that request should be reviewed or reassessed after a certain amount of time.
What's your opinion on that, and how frequently do you think the request should be reassessed?
Geriatric Physician, As an Individual
It's actually difficult to determine the frequency because we don't know how much time will elapse between the two. I also think it would be important to reassess the request, as Dr. Pageau said, when he talked about the "changing self". I don't use philosophical terms as refined as his, but he said that our self, or one's self, evolves over time. Consequently, we must let the self of persons suffering from a cognitive disorder evolve as well. We can't deny them that right.
That's why it's important to reassess requests frequently in order to ensure that patients haven't changed their mind. Some ultimately adapt to their condition or, for example, to long-term care. They may adjust to a different life and no longer want medical assistance in dying.
Consequently I can't specify an interval or number of times, but it would be important to reassess the request every time it's made to ensure that the needs have not changed.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much.
You have 13 seconds left, which is not enough time for another question. However, we have enough time for a second round of questions.
Senator, I turn the chair over to you for the second round.
The Joint Vice-Chair Hon. Marie-Françoise Mégie
Thank you, Mr. Garneau.
Mr. Ellis, the floor is yours.
Conservative
Stephen Ellis Conservative Cumberland—Colchester, NS
Thank you, Chair. I appreciate that.
Thank you again to the witnesses.
I have a couple of issues. I'll start with Ms. Iftene, if I may. I may cut you off. I'll try to be gentle with it.
You talk about misdiagnoses in the prison system, which I think does present a unique scenario in terms of how certain behaviours may be perceived. Have you ever thought about safeguards that may be required, should this be a decision made for the penal system?
Associate Professor, Schulich School of Law, Dalhousie University, As an Individual
Absolutely. The first safeguard is to make release mechanisms and other options available. We cannot divorce that discussion. As long as there aren't viable release mechanisms, it's going to be very difficult to safely implement MAID in prisons. That's not a question. There have to be other options.
I'm not not in support of MAID. I'm not in support of MAID by itself. The first safeguard is that there have to be options and there has to be oversight.
I am very concerned about the lack of oversight that is currently associated with how MAID is implemented and the fact that there is no review of the MAID cases. CSC has no obligation to conduct mortality reviews and there don't seem to be any kinds of experts on the parole board to discuss other options when someone applies for release.
