Medical Assistance in Dying Committee on Nov. 21st, 2023

[Dr. Stefanie Green]

I would say that before the model practice standards were produced, there was a lot of discussion and guidance regionally to help understand how the legislation itself might be applied in a clinical situation. As Dr. Downie mentioned earlier tonight, there's legislation that's in law and then there's clinical practice, so we have to find some understanding of whether certain situation criteria have been met under the law, and that's a clinical decision.

I would say that the model practice standard for MAID has been a significant help for those of us who were doing this work in fleshing out some of the nuances about some of the wording that's in the legislation. One of the examples might be “irremediable”, which Mr. Cooper mentioned earlier, or “incurable” and what exactly that means and what goes into satisfying that criterion. That kind of nuanced fleshing out of the meaning has been extremely helpful to clinicians, and that's why I expect that most regulatory bodies have decided to adopt those standards. Those are also being taught in the curriculum.

[The Joint Chair, Liberal, René Arseneault]

Thank you, Ms. Green and Ms. Koutrakis.

Your five minutes is already up.

Please go ahead, Mr. Thériault. You have five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Our five minutes goes by very quickly, so I will try to say as few words as possible.

Please educate me. Explain the situation to me.

Dr. Green, you talked about who would not be eligible. What would the typical patient look like?

[Dr. Stefanie Green]

It's a good question. We haven't seen these patients yet, so I can only hypothesize for you.

I think the typical patient who will meet these rarest of criteria would have to be someone with a very long, documented history of interacting with the health care system. They've had numerous treatment trials and have documented which ones worked, which ones haven't worked and how long they've had each treatment trial. They've likely had a number of hospitalizations. They've likely seen a number of specialists over the years. It would require all of that. It's not just about having that lived experience. It has to be documented in the system before I, as a clinician, could come up with what's called a medical opinion about whether they meet the criterion of incurability or irremediability.

Very unfortunately, there will be patients with that lived experience who either didn't have it documented or weren't seen adequately through the years by our medical system, for a number of different reasons. Without that robust history being documented, they likely will not be found eligible for this care.

[Luc Thériault, Bloc, Montcalm, QC]

I see. That is still a bit general and vague, but that may be the best we can do right now.

This is for all three witnesses.

As a psychiatrist, you have to determine whether a patient is a danger to themselves on a fairly regular basis. Is that correct?

Can someone give me a yes or no answer?

No one is answering.

[The Joint Chair, Liberal, René Arseneault]

Your mike is on mute, Ms. Green.

[Dr. Stefanie Green]

I'm sorry.

I'm not a psychiatrist, but it is every clinician's duty to assess each patient for suicidality. We have been doing that, not just in the context of MAID but also in our clinical practice for most of our careers.

That is correct.

[Luc Thériault, Bloc, Montcalm, QC]

The resistance to change on the ground is what worries me.

How can a psychiatrist determine the difference between a patient who is a danger to themselves and one who wants to receive MAID?

[Dr. Stefanie Green]

I think most of us have had experience, over the years, in assessing this difference. It can be complicated.

For a very simple example, I might say that somebody who has a plan to harm themselves has a timeline in which they would do it, has a means of doing so and is expressing it. It's having a kind of intuitive reaction to a negative factor in their life. They might be seen as someone who is acutely suicidal.

Somebody else requesting MAID might come in and tell you they've been talking about this with their family for months or years, and explain what their disease trajectory has been, what their values are, why they believe there's no longer any meaning in their life or why they might want to choose to end their life. They would be willing to work with the team and the clinicians to see whether that's a possibility for them, or whether there are other resources available.

There's a distinct difference between the two.

[Luc Thériault, Bloc, Montcalm, QC]

I have a question about the training you're putting together on mental disorders. Did you take into account recommendation 16 of the “Final Report of the Expert Panel on MAID and Mental Illness”, which pertains to prospective oversight?

[Dr. Stefanie Green]

In the curriculum program, we recommend following the practice standards of the local jurisdiction in which you are practising. If the local jurisdiction—say, Nova Scotia, as Dr. Gubitz talked about—requires that a psychiatrist be one of the assessors or part of the team, we would encourage our learners to do so in Nova Scotia. That may or may not be the case elsewhere. It's the same with whether there's prospective oversight or not.

[Luc Thériault, Bloc, Montcalm, QC]

The preparatory work on the ground, especially in Quebec, concerns me.

The Quebec government decided not to proceed with this measure, so what impact will this have on patients in Quebec?

[The Joint Chair, Liberal, René Arseneault]

You have 20 seconds.

[Dr. Stefanie Green]

That will be up to the CMQ, which, up until now—it's my understanding—has said that if clinicians follow one of the laws, provincial or federal, in good faith, they will not be disciplined.

I don't believe the CMQ has commented specifically about this particular situation. Certainly, publicly, they've stated they are against an exclusion. We'll have to see what they say after March 2024.

In the meantime, clinicians are preparing for the possibility.

[The Joint Chair, Liberal, René Arseneault]

Thank you, Ms. Green and Mr. Thériault.

We now go to Mr. MacAlistair for five minutes.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you, Chair. It's Mr. MacGregor.

It's okay. If I ever write a book, I'll go by the pseudonym Gregor MacAlistair.

[The Joint Chair, Liberal, René Arseneault]

I'm sorry. I'll start the time.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you.

Thank you to all of our witnesses for joining us and helping our committee go through this topic.

Dr. Green, I'd like to start with you. I appreciate the opening comments that you provided to the committee.

I am curious about the development of the curriculum. We now have the latest module, entitled “MAiD & Mental Disorders”. Are you able to inform the committee, when that module was being developed in the early days, when you became aware that Bill C-7 had passed Parliament and this was something you had to start preparing for....? Initially, in the development of that module, are you able to inform the committee what some of the initial feedback or concerns were that you were getting from people whose expertise is in this area?

What were some of the dominant themes they were bringing back that really helped to inform the development of this particular module?

[Dr. Stefanie Green]

The curriculum was put together by a group of experts who developed this content, as with all the other topics in the curriculum. We asked them for guidance on how we should move forward, and allowed them a certain leeway. They certainly looked to other jurisdictions around the world where this was already legalized to see what they could learn from those jurisdictions about what was working and what was not working.

They also collected a number of experts from across the country, mostly coming with specialty knowledge and expertise in the conditions that were primarily seen in other jurisdictions where this was legal. For example, perhaps they were those with a specialty in mood disorders or substance abuse disorders. They gathered a diverse group of subject matter experts from within Canada who have that generalized expertise based on what they were seeing in other jurisdictions that might be relevant to our experience.

Then together—I was not on that committee—they worked to develop the content, which was reviewed by over 100 different reviewers in this country. There was a multitude of stakeholders from across the country. I believe there were 18 different national stakeholders that reviewed our content before it went to the board for final approval.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you.

Ms. Campbell and Dr. Gubitz, do you have anything to add from your own personal experiences on this journey?

I see Dr. Gubitz. Please go ahead.

[Dr. Gordon Gubitz]

Sure. Thank you for the question.

There were some resounding themes as the module was being developed. They decided, as I mentioned before, to go very case-based, because that's where the meat of the matter is. They facilitated discussions so that the people who were teaching were actually subject experts in the area who could lead people through a very nuanced conversation that deals with capacity, voluntariness, irremediableness, the structural vulnerabilities that Dr. Downie mentioned in the last session, and then the concept that Dr. Green was talking about of whether the patient is suicidal or actually has a reason to wish to die, which is not the same thing.

All of those areas where clinicians struggle are basically the meat and potatoes, if you will, of the different cases in the training module, going from fairly simple to more and more complex. This is recognizing that there are probably more complex cases still, and the modules will be reviewed, evaluated and upgraded over time to reflect current practice and may include other examples going forward.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

Thank you for that.

Ms. Campbell, do you have anything to add?

[Julie Campbell]

What we can add to that is that the curriculum is a really important piece of this, but so are other forums. That richness that Dr. Gubitz was explaining in a case-based review of patients also happens in other areas in which we've gathered to become more ready: in the workshops, in an online forum and in a knowledge exchange. They all come together when we look at patents as individuals, because there isn't a list. When the law was originally written, they didn't write a list of conditions that were eligible. They listed criteria, because people don't fit into boxes very well. They are very complex, so this review of individuals and cases, gathering information from everyone in the room, facilitated by an expert, really brings out a lot of that discussion.

[The Joint Chair, Liberal, René Arseneault]

There are 10 seconds left, Mr. MacGregor.

[Alistair MacGregor, NDP, Cowichan—Malahat—Langford, BC]

That's okay. I'll cede it to the committee.