Medical Assistance in Dying Committee on April 28th, 2022

[Dr. Pierre Viens]

There are certainly many levels of palliative care. When we think of palliative care, we think especially of hospices where the quality of care is really, let's say, extraordinary. It is so extraordinary that it is impossible to believe that such care could be offered more broadly to the public.

In the beginning, there were mostly very specialized hospices. Now, at least in Quebec, there are good palliative care services in almost every hospital, large or small. I have nothing against that at all. Palliative care is and always will be necessary.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

What I'm asking you, Dr. Viens, is how to define quality palliative care. How does it differ from palliative care of lesser quality ? What does it mean for the patient?

[Dr. Pierre Viens]

What is palliative care?

Palliative care is comfort care. It is not intended to cure, and patients at the end of life have only comfort care to relieve them.

What is comfort care? It varies in nature. It can be treatment, pain management and management of other physical symptoms, such as nausea, balance problems, and so on. Beyond that, there is the whole category of what is called psychological suffering, including existential suffering at the end of life. There is no pharmaceutical treatment or any other treatment sufficient to meet the needs of these patients. I don't think there ever will be.

I was a doctor in an excellent hospice for 25 years, before I devoted myself exclusively to medical assistance in dying. I had to because in that hospice, when the law was passed...

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Dr. Pierre Viens]

I will try to summarize, Mr. Arseneault.

In my view, good palliative care is comfort care that is available to people wherever they are, even at home, and is sufficient to meet their needs satisfactorily.

Higher quality palliative care...

[The Joint Chair, Hon. Yonah Martin]

Thank you.

[René Arseneault, Liberal, Madawaska—Restigouche, NB]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Next is Mr. Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you very much, Madam Chair.

Dr. Viens, I will let you finish your answer.

You were talking about the accessibility of palliative care.

[Dr. Pierre Viens]

In my opinion, good palliative care is comfort care that is accessible and satisfactory in the majority of cases.

I will give an example. There are different levels of pain management, but what is important is to make basic treatment techniques and approaches accessible. That's why it's not necessary...

[Luc Thériault, Bloc, Montcalm, QC]

I am sorry to interrupt, but I want to address another aspect of the issue.

Quebec's approach was forward-thinking, in that they implemented end-of-life care legislation under which palliative care is the vehicle for end-of-life care. Rather than debating this, as many do, or pitting palliative care and the request for medical assistance in dying against each other, Quebec has included the emergence of a request for medical assistance in dying within a continuum of end-of-life care.

I assume that this approach is acceptable to you.

Isn't it?

[Dr. Pierre Viens]

Not only does it suit me, but personally it is the approach I have always used.

[Luc Thériault, Bloc, Montcalm, QC]

Some claim that when palliative care is optimal, it leads to people not seeking medical assistance in dying.

In your 25 years of practice in this field, has this been your experience?

[Dr. Pierre Viens]

I experienced it profoundly.

When I started working in the field of palliative care, I was working at Maison Michel-Sarrazin.

The Maison Michel-Sarrazin is one of the most renowned homes for quality care. When I started working there, the law on medical assistance in dying did not exist. After a few years, I realized that even with more extensive palliative care, whether in the form of drug therapy or other supportive therapies, we were not able to respond to suffering on a psychological level, such as existential suffering.

To really respond adequately to patients at the end of life who asked us for relief, I always thought that the range of palliative care available was not always sufficient, especially to respond to this well-known existential suffering.

That is why, after the Act respecting end-of-life care came into force in Quebec in 2015, the Collège des médecins du Québec defined medical assistance in dying as being part of the continuum of palliative care. In other words, it is palliative care along with other forms of care. It is intended to respond, at the patient's request, to situations that traditional palliative care does not address.

In my practice, I have never had to deal with a conflict opposing palliative care and medical assistance in dying.

[The Joint Chair, Hon. Yonah Martin]

You have 30 seconds.

[Dr. Pierre Viens]

I respond to all the MAID requests I receive by providing the best palliative care at my disposal. As I see it, there is no conflict. There's no difference between medical assistance in dying and other palliative care measures.

[Luc Thériault, Bloc, Montcalm, QC]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Next is Mr. Johns for five minutes.

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

Madam Co-Chair, I'm actually back in the committee.

[The Joint Chair, Hon. Yonah Martin]

Okay, Mr. MacGregor. Go ahead.

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

Thank you very much.

Thank you, Mr. Johns, for holding a spot for me.

Thank you to our witnesses. I'm sorry I missed your opening statements. Forgive me if I cover some of the same ground, but maybe it can give you a chance to expand on earlier answers.

We had a meeting earlier this week, on Monday, at which the topic of palliative care was also covered. We heard from some of our witnesses that many Canadians do not understand palliative care. In many cases, they are referred to it far too late in their end-of-life stages. They could have been better served had they been aware of it earlier and granted access to it earlier.

Perhaps I'll start with Dr. Kaya and then invite each of you to respond. When it comes to specific recommendations that our committee can be making to the federal government, what can we do to ensure that more people are better informed about palliative care supports that are out there? How can the federal government be supporting provinces to ensure that the information is out there even in remote communities, which may not have the best access the way our big city centres do?

[The Joint Chair, Hon. Yonah Martin]

Dr. Kaya, please go ahead.

[Dr. Ebru Kaya]

Thank you.

We definitely need increased funding and resources in palliative care, but it needs to be separate and distinct from MAID. Currently, essentially all of us are competing for the same resources. As I mentioned before, we have palliative care nurses in many of our provinces who are doing MAID assessments instead. My community is distressed. We're burnt out. We're being asked to do more with less. Some of our community members have retired early. Others have left the field.

Really, we need to be able to provide a sustained investment in palliative care. We have some of the best researchers in palliative care here in Canada, but when it comes to our clinical programs, we are way behind other developed nations. That definitely needs to change.

In terms of the communication around this, as national organizations representing palliative care in Canada, we would love to be able to meaningfully engage with our government officials. As the experts in the field, we can help you with the information you need, and the guidance, so that we can work together and improve palliative care in Canada for Canadians together. We can't do this if we're ignored or if we're called at the eleventh hour.

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

Thank you very much.

Go ahead, Dr. Downar.

[Dr. James Downar]

I absolutely think we do need to continue to redouble our efforts to improve the quantity and quality of palliative care that Canadians receive. As a rule, most Canadians can and should be getting palliative care approaches integrated earlier than they currently are. I think it's important, though, to distinguish this from the MAID question. There really isn't any indication that this is what's driving MAID on any level. When palliative care is involved, it's often involved for quite a substantial amount of time before MAID requests go in and before MAID is provided.

I just want to correct the misconception that this study data comes from only self-reported surveys, which I think Mr. Barrett had asked about before. That's not true. We did a study in Ontario. In Ontario, every single case is reviewed by a nurse investigator working for the office of the chief coroner. Obviously, these are people with no skin in the game who would stand to lose or gain nothing from any of their assessments. Their assessments concurred almost exactly with the same numbers in terms of the involvement of palliative care duration. I think that's really important to state. MAID is provided to maybe 2% or 3% of the population as they die.

The importance of palliative care, social services and improving all of those things that we do for Canada's most vulnerable and Canada's dying are vitally important, because it applies to 97% of the population, the part that doesn't get MAID. I've gone two or three years now without doing a single MAID case. I'm a palliative care physician. Since moving to Ottawa I haven't done it. There's a lot more palliative care to be done out there than there is MAID. That's really where the emphasis should be. I don't think you want to mix and confuse these two.

It's also important to state that the shared pool of resources is a misconception. In Ontario, certainly, there isn't a shared pool of dedicated palliative care resources. It's a physician services budget, one where anyone could bill any amount of codes. It doesn't come at the expense of palliative care. Where there are nurses....

Sorry. I'll stop there. Thank you.