Evidence of meeting #4 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 medical.
A video is available from Parliament.
7:50 p.m.
Conservative
Marilyn Gladu Conservative Sarnia—Lambton, ON
Thank you, Chairs, and thank you to all our witnesses.
I want to talk about palliative care. As a result of the special committee that studied the Carter decision and their recommendation that in the absence of good quality palliative care, you actually don't have a choice, I brought forward Bill C-277 to create a palliative care framework, which I am very proud of.
The government pledged $6 billion over 10 years in the 2018 budget for palliative care. Sadly, what's happened is that they've spent only $200,000 of that, and it was bucketed together with MAID, which was never the intent. The World Health Organization has been clear that palliative care does not hasten death; that's a totally different thing from MAID.
My first question is easy and for each of you. We know that the framework was also looking at addressing the 60,000 missing resources in terms of palliative care doctors, nurses and other providers. Would you agree that the government should meet its commitment of $6 billion over 10 years for palliative care and address the gap of missing resources?
Dr. Buchman, I'll start with you.
7:50 p.m.
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
I agree one hundred per cent. It's a shame that the funding did not follow the framework. That's been the consistent place in Canada. We have wonderful plans, but they end up sitting on a shelf because the funding never comes.
When Australia created its assisted dying legislation a couple of years back, they pledged a very significant amount for palliative care at the same time. I think it is incredibly important to do that.
7:50 p.m.
Conservative
7:50 p.m.
Distinguished Professor of Psychiatry, University of Manitoba, As an Individual
Yes, absolutely.
Again, congratulations on the framework. As Dr. Buchman was saying, the fact is that we don't have the services available for patients and their families. I don't think we can take any comfort in the fact that 15% to 30% of people have access to these resources. It's shameful that we just don't have better care available.
In preparation for today's presentation, I spoke to the head of our medical palliative care program, and, for your information, Winnipeg—a city of about a million people—has not seen an increase for palliative care funding in the last 20 years. We have 16 hospice beds, all located within the perimeter highway—
7:55 p.m.
Distinguished Professor of Psychiatry, University of Manitoba, As an Individual
—and none beyond that in Manitoba, so we're woefully lacking.
7:55 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you very much, Madam Chair.
I want to thank the witnesses for coming and giving their time so late in the evening.
I listened to the last meeting that we had and this meeting, and I am hearing different stories about palliative care. As a physician, I think I know what palliative care is, and I have heard some of our palliative care physicians explain what it is. It is a part, at the end of day, of a continuum of care. It is not the same care, and it is not necessarily parallel care, but it is a continuum of care.
I've also heard that there are competing resources. We had our Library of Parliament research some of this first, and I have not necessarily found that to be true.
With regard to money being given by the federal government for palliative care and a framework, that palliative care money goes to provinces. The federal government, except for indigenous people and the armed forces, etc., does not do this itself. It gives it to provinces, so it all depends on where provinces decide to put their money and their priorities. I know in some provinces there isn't enough money for home care within the palliative care system.
However, I would like to understand what happens if—and I'm going to ask Dr. Buchman this—a patient comes to you.... You pointed out three very important parts of end-of-life care: the physical care, the psychosocial care and the existential issue. Now the psychosocial care we understand. It's mostly women and a lot of people who live alone, obviously isolated, etc., but not a lot of people are talking—other than Dr. Viens, who talked about it today—about the existential care, about the fact that you can take away the pain, you can make people comfortable, and you can bring people around them to deal with their loneliness, but at the end of the day, there is that piece, that spiritual part, of a person considering what their options are.
If a patient came to you with a chronic disease and chronic pain, and you went to palliative care with them, and they seemed to be getting the help in the physical and psychosocial arenas.... After a while, patients have their needy sides from an existential point of view that this is not living. This is not quality-of-life care. This is not really living, and they want more, and they want to make a decision to probably end their life on their terms. What would you say to that person? Would you insist that they continue at palliative care or would you explain the options in a simple way, regardless of language, etc., allow them to make that decision and respect the decision of the individual about their person?
7:55 p.m.
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
We see these patients virtually every day. What happens is that you do everything possible to address their suffering in those domains I referred to before, including existential and spiritual suffering. Part of the frustrations that many of us have with the system is that, if I want to refer for spiritual care or anticipatory grief or even family members for grief and bereavement, the access to those services is very poor. We have long waiting lists.
We have to often take it upon ourselves to address that suffering. I guess I've always worked on the principle that I will do whatever possible to address their suffering, everything short of MAID, but ultimately, if that person insisted that everything we have tried was not acceptable to them, which is consistent with the law, then I would agree to an eligibility assessment for them with regard to medical assistance in dying.
8 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you, Dr. Buchman.
I want to go to Dr. Tremblay.
I think you've also expressed that same sort of sense, that it is about the patient at the end of the day. It's not just about what the physician thinks; it's always going to be about the patient.
Can you tell me what you would do with that patient who went through palliative care and then decided that they wanted to end their suffering?
8 p.m.
Physician, As an Individual
A patient who requests a treatment option that the doctor cannot provide is obliged to go to another source. For example, if a cardiologist needs the opinion of a respirologist, he will seek the opinion of a respirologist. It's that simple.
Some doctors are willing to offer medical assistance in dying and some patients ask for it. It is not for the doctor to say whether it is right or wrong. The doctor must assess the patient. All those who offer medical assistance in dying must do so, and must continue to do so. One does not exclude the other.
8 p.m.
Liberal
Hedy Fry Liberal Vancouver Centre, BC
Thank you.
Thank you for clarifying it, Dr. Buchman and Dr. Tremblay.
8 p.m.
Liberal
8 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Thank you very much, Madam Chair.
Dr. Tremblay, in another forum we can have a debate on Quebec's legislative intent. I would now like to move on to another question.
Palliative care, as conceived by Ms. Cicely Saunders, consists of a holistic approach, accompaniment towards death, relief of pain and suffering on the psychic and physical levels, as well as accompaniment of the family, and this in the most natural environment possible.
When palliative care was started, it did not mean leaving the patient to die in a corner. Palliative care helps to slow down the process of dying when it has irrevocably set in. Patients feel better and do better when they are in a palliative care unit. Sometimes they even have to be taken out of the unit because they cannot stay there for more than three months. You are right to demand more access to palliative care.
My next question is for Dr. Buchman and Dr. Tremblay.
If a patient at the end of life, who has received very good palliative care, who has been well supported and who feels serene and ready to let go, asks for medical assistance in dying, do you consider this a failure of palliative care?
Why should we separate these two approaches when they are part of a continuum of end-of-life care?
8 p.m.
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
I don't think that it's a failure of palliative care. It's unlikely a person will just wake up one morning.... But the wish to hasten death is very common in our field. At times, despite our best efforts...like anything in medicine, there are limitations to what we can do. It may be that we are just unable to address the suffering in ways that are acceptable to the patient.
Ultimately, Canadians have that access for eligibility, but it's also true that the presence of the MAID law allows us to deliver palliative care.
I had a patient with HIV and ALS, and he had no use of his upper body or his arms. He was completely dependent on others for feeding and for personal hygiene. He lived on the 22nd floor of a high-rise in Toronto, where I cared for him, and he told me it was the MAID law and his opportunity to choose or to have that choice when he was ready.... Otherwise, he accepted everything that we could do in palliative care. It was the MAID law that allowed him to accept palliative care, or he stated clearly that he would have jumped. The overall answer is that it doesn't happen immediately. We have limitations, and the presence of the MAID law often allows us to deliver excellent palliative care to the best of our ability.
8:05 p.m.
Physician, As an Individual
There can be many interpretations, and they are related to each person's experience. It is a highly emotional subject. We need to get data and do studies to find out what really motivates patients to ask for medical aid in dying, to understand what is going on.
Similarly, we need indicators in palliative care to be able to understand the bigger picture and understand the situation. If you decide to put a policy in place, you need indicators to monitor the situation. If there are no indicators, how do you know if it's working, if it's going well, or if there are failures and collateral effects?
8:05 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Are you one of those who think that a patient who applies for medical aid in dying should be excluded from a palliative care unit from the outset?
This is done in some institutions.
8:05 p.m.
Physician, As an Individual
In this regard, I would say that patients who are in a palliative care unit need specialized care. So that means that their condition is complex. In my opinion, these beds should be kept. So it's not a question of being for or against, but it's a question of resources. We need to keep these specialized beds and the use of these specialist doctors for complex cases, i.e., cases like these.
8:05 p.m.
The Joint Chair Hon. Yonah Martin
Thank you.
Next we will have Mr. MacGregor for five minutes.
8:05 p.m.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you very much, Madam Co-Chair.
Dr. Buchman, I'd like to direct my questions to you.
You made mention of the fact in your opening statement that you have provided palliative care for homeless people—a very vulnerable population. I think you bring a unique perspective, because you say walk in both lanes. You have also been a MAID assessor and provider.
In your work with the homeless, you're dealing with a very vulnerable population, where the social determinants of their health are very obvious and present. They have had housing insecurity, they often don't know when their next good quality meal will come, and they live a life, on a daily basis, which is full of uncertainties and incredible stress on their health.
When someone has an incurable disease, an irremediable medical condition, and they're either being assessed for access to palliative care or maybe their choice is to go to medical assistance in dying, can you talk a little bit about what effect those social determinants have on their health? Do you often run into conditions where, if that population had earlier access or better access to health care, the state they are in when they first see you could have been prevented?