Evidence of meeting #39 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 illness.
A video is available from Parliament.
Counsel, Criminal Law Policy Section, Department of Justice
Just to make sure I understand the question, it's about whether the safeguards in the Criminal Code are sufficient to protect—
Counsel, Criminal Law Policy Section, Department of Justice
I think that is ultimately up to Parliament to decide. I can't speak to any advice that's been provided to the government on—
Liberal
The Joint Chair Liberal René Arseneault
Thank you, Ms. Willis.
Madame Martin, the floor is yours for three minutes.
The Joint Chair Hon. Yonah Martin
Thank you, Mr. Chair.
I just wanted to say that I do share the concerns of Mr. MacGregor about the lack of consultation with indigenous communities. You said that you have done some broad consultation, but nothing specific to MAID and mental disorder. We heard testimony previously from some of the members of the indigenous community that there has been quite an absence of consultation. That is quite concerning to me.
Professor Lemmens, I'm aware that you have recently been a member of an expert panel for the Jersey government that made recommendations about assisted dying legalization options. I have two questions. Were any of the committee findings and legislative options informed by Canadian MAID law and practice? Was there any discussion about MAID and mental illness?
Professor, Scholl Chair, Health Law and Policy, Faculty of Law, University of Toronto, As an Individual
Thank you for the question.
I should say that we were not mandated to discuss the rationale for legalization. Jersey put forward two options for legalization. One was a terminal illness diagnosis, kind of styled track one but narrower than in the Canadian context. The second one was a very broad track, which compares with the Canadian track two. I was not completely surprised, but I was happily surprised, to see that my two colleagues, who actually are for the legalization of assisted dying in some form, agreed, looking at the evidence, that the Canadian model was not the approach they should be taking.
We actually recommended against an open-ended access to MAID for unbearable suffering. Psychiatric MAID is explicitly excluded, as it is in most jurisdictions around the world, or in many jurisdictions around the world that have legalized some form of assisted dying. Simply, this is also because most jurisdictions limit access to MAID or euthanasia or assisted suicide in the end-of-life context to people who have a terminal illness diagnosis, where mental illness would not fulfill the criteria of a clearly identifiable survival prognosis or terminal illness prognosis.
The Joint Chair Hon. Yonah Martin
You mentioned both Belgian and Dutch euthanasia regimes in your remarks. Do you have more concerns about MAID for mental illness in Canada than those other regimes?
Professor, Scholl Chair, Health Law and Policy, Faculty of Law, University of Toronto, As an Individual
I think people have to realize that the fundamental difference between the Canadian system and Belgium and the Netherlands is that we don't even have an obligation that physicians have to agree that all reasonable treatment options are fulfilled. People are saying, oh, there will be only a few cases. It is practised more broadly already than in a few cases in Belgium and the Netherlands. It will be practised much more broadly in the Canadian context because of individual choice—
Liberal
The Joint Chair Liberal René Arseneault
Thanks, Professor Lemmens. I'm sorry, but we're so tight.
We won't have time for a second round during this first hour, so we will suspend briefly to let the witnesses take their leave and bring in our panel for the second hour.
Thank you to the witnesses, Ms. Willis, Ms. Voisin, Ms. Downie and Mr. Lemmens.
Liberal
The Joint Chair Liberal René Arseneault
We are now beginning the second hour of today's meeting. Please take your seats.
Welcome to the witnesses, who are all joining us remotely. During the second hour, we have with us, as an individual, Dr. Stefanie Green, MAID practitioner and adviser to the British Columbia Ministry of Health; Julie Campbell, nurse practitioner, Canadian Association of MAiD Assessors and Providers; and Dr. Gordon Gubitz, division of neurology, department of medicine, Nova Scotia Health.
We are really pressed for time today, so you will each have five minutes to give your opening statements.
We will start with you, Dr. Green.
You have the floor for five minutes. It's very tight.
The floor is yours.
Dr. Stefanie Green President, MAID Practitioner, Advisor to BC Ministry of Health, As an Individual
Thank you for this opportunity.
My name is Stefanie Green, and I'm a physician with 30 years of clinical experience.
In June 2016, I began working almost exclusively in assisted dying. You may read of my credentials in my written brief. I've no personal or professional stake in the outcome of your deliberations, but I remain committed to providing the highest standard of medical care possible under any and all legislation.
If the purpose of this committee is “to verify the degree of preparedness attained for a safe and adequate application of MAID” in MD-SUMC situations, your work should not be complicated. Clearly, there is a high degree of preparedness. I point your attention to the numerous readiness activities plainly outlined in the written brief of CAMAP, and those referenced by Dr. Mona Gupta and Dr. Douglas Grant, and tonight by Professor Downie.
There is readiness at the federal level. There is stated preparedness by the medical and nursing regulatory bodies, as well as by professional associations. Clinical teams in British Columbia, Alberta, Saskatchewan, Ontario and Nova Scotia have all confirmed their readiness. I can speak more to this in our discussion if you wish.
Regardless of what this committee ultimately recommends, I am most concerned that it be based on fact and not on any fundamental misunderstanding. I submit the following three points of information for clarity.
Number one, consensus is not and has never been required in the development of medical practice. There's no consensus on many medical practices—hormone replacement therapy for women, safe injection sites, use of ketamine for treatment-resistant depression. This lack of consensus is not taken as a reason or justification to prohibit these practices. There is no consensus among clinicians about MAID itself, yet that did not and does not stop MAID from being permitted under the law.
Medical practice does not start with training all clinicians before the practice is permitted; rather, it starts with training some, who then train others over time. Only clinicians with the professional competence to provide the intervention are permitted to do so, by the standards already published and already enforced by the colleges of physicians and surgeons or colleges of nurses in every province and territory.
Any suggestion that consensus is required before moving forward with MD-SUMC is opposition to MAID disguising itself as a benchmark.
Number two, legislation is clear regarding MAID eligibility. We need to stop focusing our attention on a person's diagnosis, mental disorder or otherwise, and look to the eligibility criteria—the condition must be incurable, irreversible, unrelievable.
Clinical understanding and implementation of MAID legislation continues to evolve and mature. The recently published model practice standard for MAID has contributed significantly to this understanding.
As an experienced MAID practitioner and as one who teaches others how to approach this practice, I would state as clearly as possible for your recognition that in situations of MD-SUMC, someone in crisis is not eligible for MAID. Someone who is newly diagnosed is not eligible for MAID. Someone who hasn't had treatment, or refuses all treatments with no rationale, or is seeking MAID due to socio-economic vulnerabilities is not eligible for MAID.
Number three, we have enough psychiatrists already involved to move forward. Legislation requires two independent clinicians to find a patient eligible before they can proceed. For patients whose natural death is not reasonably foreseeable, a clinician with expertise in the condition causing the person's suffering must also be involved.
Psychiatrists may therefore potentially play two different roles: they may be assessors or providers of MAID, although few will be required for this role, or they may be consulted as clinicians with experience in the condition causing the person's suffering. Psychiatrists are already being consulted as clinicians with expertise in many applications, because they already possess the skills and training to be considered experts in their field. Canada has nearly 5,000 psychiatrists already adequately trained to continue to fulfill their role of expertise in MD-SUMC situations.
Over 100 psychiatrists have already registered their interest in becoming involved in MD-SUMC. This represents 2% of all psychiatrists in Canada. Last year, about 2% of all physicians in Canada provided 13,000 MAID procedures. I would suggest that 2% of our psychiatrists are sufficient to consult on what is rationally expected to be significantly fewer MD-SUMC cases.
Preparedness for MD-SUMC is clear. Please do not let misinformation distract or cloud your deliberations on this point.
Thank you.
Liberal
The Joint Chair Liberal René Arseneault
Thank you, Dr. Green.
Now we will hear from Ms. Julie Campbell.
The floor is yours for five minutes.
Julie Campbell Nurse Practitioner, Canadian Association of MAiD Assessors and Providers
Thank you for inviting me here today.
My name is Julie Campbell. I'm a nurse practitioner and the vice-president of the Canadian Association of MAiD Assessors and Providers, or CAMAP. CAMAP represents professionals who work in the delivery of MAID in Canada. CAMAP does not take a position on MAID MD-SUMC. We are focused on, and committed to, supporting our members to provide the highest standard of medical care within the law.
As part of this commitment, CAMAP has, over the past two and a half years, developed the Canadian MAID curriculum, or CMC, the first comprehensive, nationally accredited, bilingual and evidence-based educational program to support the practice of MAID in Canada. It aims to educate new MAID practitioners, advance the skills of existing MAID practitioners, and help standardize the approach to care by supporting those who deliver MAID care from coast to coast. On August 21, 2023, the CMC was launched, and the enthusiastic response from clinicians exceeded expectations. Feedback from clinicians who have completed modules has indicated very positive responses when asked if they felt that their knowledge and confidence had increased.
In addition to expertise in MAID assessment and provision, CAMAP members also carry a variety of clinical expertise in many areas, including psychiatry. Our members rely on colleagues who act as consultants in their area of expertise. When an assessment is completed for a patient without a reasonably foreseeable natural death, and for whom neither assessor has both expertise in MAID and expertise in the condition causing the patient's suffering, we rely on these consultants to provide their expertise in the condition to add to the assessors' expertise in MAID assessment.
The difference between the role of assessor and the role of consultant is important to understand. Our psychiatrist colleagues have, by virtue of their extensive training and expertise as psychiatrists, advanced knowledge on capacity decisions and mental disorders. We have utilized their skills as consultants for any patient who requires it. This is not specific to patients with MD-SUMC, and it may apply to both patients with and without a reasonably foreseeable natural death. For patients with MD-SUMC, we will utilize their skills once again.
In Canada, there are approximately 5,000 psychiatrists who, by virtue of their education and skill, may act in the role of a consultant. Included in that, there are psychiatrists who have sought and obtained expertise in MAID assessment. To date, more than 100 psychiatrists have begun or completed training with the CMC, demonstrating a significant level of interest of this subset of psychiatrists, who will then both be a source of expertise from their respective backgrounds and have expertise as assessors.
Since 2016, we have safely assessed patients requesting MAID who also had comorbid mental disorders. Part of our thorough, thoughtful, and safe approach to eligibility assessment has always been to see the patient as a whole. To help our members, we have developed clinical guidance documents such as “Assessment for Capacity to give Informed Consent for Medical Assistance in Dying (MAiD)” and “Medical Assistance in Dying (MAiD) Assessments for People with Complex Chronic Conditions”. These documents have helped guide our members to safely assess and provide for patients with complexities. They have helped us develop experience that will be relevant to assessing patients with requests for MAID MD-SUMC.
As is standard in medical practice, we are evolving each day, sharing our best practices and gaining experience, and we now have almost seven years of experience upon which to draw. We have organized and facilitated knowledge exchange workshops with representatives from across Canada. One knowledge exchange was focused on clinician readiness, and the other on system readiness, to ensure not only that the clinicians are ready, but that the other important members of our teams are also ready—namely, nurses, social workers and administrators, among others. We have hosted a three-part fall symposium with specific learning around assessing individuals with mental disorders. We hold monthly case-sharing webinars. We have prepared diligently for the expiration of the sunset clause, and we are ready.
CAMAP members are ready for the planned legislative change in March 2024 and will continue to provide compassionate and high-quality care to all patients considering MAID.
Thank you.
Liberal
The Joint Chair Liberal René Arseneault
Thank you, Ms. Campbell.
Dr. Gubitz, please go ahead. You have five minutes.
Dr. Gordon Gubitz Head, Division of Neurology, Department of Medicine, Dalhousie University and Nova Scotia Health Authority
Thank you, and good evening from Nova Scotia.
My name is Gord Gubitz, and I am very grateful to be able to speak to you today. I'm a professor of medicine and neurology at Dalhousie University. I became a MAID assessor and provider for both track one and track two patients after legislation was passed.
I'm also a board member for the Canadian Association of MAiD Assessors and Providers, and I sit on their education committee. I was the chair of the national group from CAMAP that developed the MAID curriculum you've heard about, which was discussed earlier. Hopefully we'll have a chance to discuss it in the question period.
I'm also the clinical lead for MAID in Nova Scotia. That involves working on a weekly basis with our administration in collaboration with the Department of Health to oversee MAID in our province.
I'm pleased to speak to you this evening on behalf of Nova Scotia as an example of jurisdictions across the country to help you understand why Nova Scotia stands ready to move forward with caring for people who request MAID for MD-SUMC, starting in March 2024.
Each province and each territory will deal with this differently. In Nova Scotia, we have one central team that is managed and overseen by a very strong administrative staff with skilled nurse navigators who triage and assess patients and provide detailed assessments and referrals. We also have full-time nurse practitioners who work geographically to help provide MAID. In the wake of Bill C-7 and in anticipation of the complexities of track two, we have recruited additional members to our team, including social workers, etc.
Our team is involved with regular education with learners across the province. Importantly, our team meets on a regular basis every week on Friday morning to review “challenging cases”, as we call them. Many of these people have complicated medical problems and are often track two patients, many with underlying mental health issues.
With respect to MD-SUMC, we recognized that we would need to start to do this work some time ago, and have been working for over 18 months to ensure that Nova Scotia is ready. We created a provincial working group to develop policies and processes that would serve the MD-SUMC population. It was beneficial to have all of the national work that was done to help guide us.
Our plan was to be ready for the implementation by March 2023. To do this, we hired additional staff with mental health expertise. Thus, one of each of our nurse navigators, nurse practitioners and social workers has a clinical background in mental health. We're in the process of exploring psychology consultancy, and we are recruiting an MD-SUMC clinical lead in psychiatry. This person will hold a position similar to mine but with a focus on mental health. The two of us will work collaboratively with our MAID team, as our skill sets are similar and complementary.
Our working group was chaired by two psychiatrists, one of whom also does complex MAID assessments where capacity is an issue. The working group included members of our core MAID team, hospital and community-based psychiatrists, a specialist in addictions medicine, a bioethicist, a psychiatry resident and representation from our government. As the process moved forward, we included one of our social workers and a nurse navigator with mental health experience.
The working group was tasked with completing a detailed scoping review of the various topics relevant to MAID and MD-SUMC. It developed detailed and practically useful background material and guidance documents that will support clinicians in Nova Scotia in their day-to-day work. We also provided overall governmental recommendations.
To this point, we have an ethical framework that has been based on a systematic review of the emerging area of palliative psychiatry. We have detailed documentation and training materials for the required assessments, including a comprehensive process that focuses on determining capacity, voluntariness, irremediability and structural vulnerability, and understanding suicidality versus a reasoned wish to die. We also have clinical pathways, including a modified intake process that will be completed by the nurse navigator, specifically built for MD-SUMC.
We've followed along with a specific recommendation. One of the two MAID assessors in Nova Scotia must be either a psychiatrist or an addictions specialist, depending on the case.
We are engaged in a prospective review similar to our weekly complex case discussions. Thus, our track two discussions every Friday morning will increasingly begin to involve people with mental health as a sole underlying condition. We will also be undergoing retrospective case audits for each person who completes the process of MAID using a standardized process. We've developed post-intervention supports for clinicians, families and friends.
In conjunction with CAMAP, we are developing training programs, including the modules that have been described previously, and we're looking at compensation models. We have shared all of our documents with the other jurisdictions across the country, as Ms. Campbell outlined in the presentation that she gave. We have engaged in some really interesting provincial and territorial discussions.
Over the coming months—
Liberal
The Joint Chair Liberal René Arseneault
Thank you, Dr. Gubitz. You can elaborate later on through the questions that will be asked of you.
We will now have questions from members of the various parties. They will each have five minutes.
Please go ahead, Mr. Cooper.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you very much, Mr. Chair.
Dr. Green, I want to clarify that you are appearing in your capacity as an individual and not on behalf of the B.C. Ministry of Health. Is that correct?
President, MAID Practitioner, Advisor to BC Ministry of Health, As an Individual
Yes, I am absolutely here tonight as an individual practitioner and not on behalf of any organization.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
Thank you very much for that.
You indicated that with respect to the CAMAP curriculum, it was first rolled out on August 31. It's my understanding there are eight different modules. How many professionals have been enrolled in module seven on MAID and mental disorders?
President, MAID Practitioner, Advisor to BC Ministry of Health, As an Individual
I'm sorry, but who was the question for?
Nurse Practitioner, Canadian Association of MAiD Assessors and Providers
I don't have that data this evening, but I could provide it.
Conservative
Michael Cooper Conservative St. Albert—Edmonton, AB
It's my understanding that it has only very recently been rolled out or that it may not have been rolled out. Is that correct?
Nurse Practitioner, Canadian Association of MAiD Assessors and Providers
It has been rolled out. Module seven for mental disorders has been rolled out and has occurred in numerous locations.
Perhaps Dr. Gubitz has more information on that as well.
Head, Division of Neurology, Department of Medicine, Dalhousie University and Nova Scotia Health Authority
I'm sorry, but I don't have the specific numbers. However, the modules, as they are in the process of being rolled out, require interested practitioners to apply and register to go through the online pre-learning and then the facilitated module. You are correct that over the coming months there will be increasing numbers involved in the training, but several groups have gone through already.