Thank you, Mr. Chair.
Thank you for the invitation to come and discuss this important topic with you.
I will begin with a brief introduction.
I am a geriatric physician at the Institut universitaire de gériatrie de Montréal, which is part of the Centre intégré universitaire de santé et de services sociaux du Centre-Sud-de-l'Île-de-Montréal. I have had additional training in pain and palliative care. For the past 20 years or so, I have practised almost exclusively at a chronic pain management clinic for the elderly.
I have been interested in medical assistance in dying since it first became a topic of discussion in Quebec. Although I am a member of Quebec's Commission sur les soins de fin de vie, I wish to point out that I am not speaking here on its behalf, but rather as an individual.
I practise medical assistance in dying, on average, once or twice a month, in some instances for patients whom I have been following for a very long time and in others for patients for whom I have been asked to consult on this specific care. Given my clinical expertise, I normally assess people whose eligibility is unclear or whose natural death isn't reasonably foreseeable. Some of those persons suffer from major neurocognitive disorders.
I also lecture regularly on medical assistance in dying to health professionals and the general public.
Today, I would like to discuss the most important points regarding advance requests for medical assistance in dying for persons with a major neurocognitive disorder.
First, I obviously can't comment on the opinions of Canadians across the country. However, I can rely on the testimony given to the special parliamentary committee of the National Assembly of Quebec last fall and on comments I have gathered during my lectures on the subject and in my practice. Based on that information, I believe there is fairly broad acceptance of advance requests in Quebec in the general population and among persons with major neurocognitive disorders and their loved ones. There is also fairly broad acceptance among health professionals, even though some anticipate implementation issues. Consequently, the Quebec public expects that medical assistance in dying can be made possible by advance requests, and many individuals were greatly disappointed when the bill on this topic had to be abandoned in the spring.
In the present circumstances, since the criterion of reasonably foreseeable natural death was removed, persons suffering from major neurocognitive disorders may be eligible for, and may receive, medical assistance in dying. There is a brief period in disease development where the disorder is grievous enough that it causes advanced and incurable decline in capacity but not yet grievous enough to compromise the patient's ability to request medical assistance in dying. In my experience, persons with a major neurocognitive disorder who request medical assistance in dying wait as long as possible before doing so. In many instances, they do it just before losing that ability, such that, in some instances, the 90-day period must be shortened because loss of capacity is imminent. If they could make an advance request, many of them would probably choose not to request medical assistance in dying at that time so they could continue enjoying happy moments with their loved ones. Consequently, they die sooner than they would have wished. In that sense, it can be said that their right to life, guaranteed under section 7 of the Canadian Charter of Rights and Freedoms, is thereby violated, as the Supreme Court held in the Carter judgment, since, in order to be granted access to medical assistance in dying and not to deteriorate until the end, those persons must die earlier than they would have wished.
I therefore believe that the act should be amended to allow advance requests for medical assistance in dying for persons with major neurocognitive disorders. This is nevertheless a very complex issue from both ethical and implementation standpoints. First of all, it is very difficult to assess suffering, which is, by definition, the subjective experience of a person incapable of communicating it. In some cases, there is undeniable objectifiable suffering, accompanied by non-verbal signs of pain and psychological and behavioural symptoms associated with dementia, such as aggressiveness. In other cases, which are, rightly or wrongly, called pleasant dementia cases, patients are happy in their day-to-day lives despite their cognitive disorders and loss of autonomy. However, if they had seen themselves in that state, they might not have wanted to live. Should the eligibility criterion be contemporaneous suffering or anticipated suffering? That's an important and complex question.
Another important question arises regarding the situation in which the individual making an advance request refuses to cooperate when the time comes to administer medical assistance in dying. At an advanced stage, many individuals resist all contact and treatment and become aggressive when touched. As a result, they reject attempts to insert any intravenous device without previously being sedated or restrained. Even though patients, when they were competent, probably wanted to be sedated or restrained for the purpose of administering medical assistance in dying, are we to disregard their verbal or physical refusal when they are no longer competent? Many clinicians say they would find it very difficult to do so, especially if patients showed no signs of objectifiable suffering.
In short, I think that the act should be amended to allow a person to make an advance request for medical assistance in dying. However, the guidelines and practice guides should be very clear in order to support clinicians who are involved when medical assistance in dying is requested or administered.