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.
7:10 p.m.
The Joint Chair Hon. Yonah Martin
Thank you very much.
Time is up. I will now turn this over to my co-chair for questions from the senators.
7:10 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Co-Chair.
We'll proceed with questions from senators. These are three-minute rounds.
We're going to start with Ms. Mégie.
You have three minutes, Senator.
7:10 p.m.
Marie-Françoise Mégie Senator, Quebec (Rougemont), ISG
Thank you, Mr. Chair.
I'm very glad to have palliative care experts with us today. Having been a family physician for 30 years, I am in my element.
My first question is for Dr. Kaya.
First of all, thank you for your opening statement.
You brought up national standards earlier. I think they are needed, but how much of a difference do you think national standards can make in palliative care?
7:10 p.m.
Associate Professor of Medicine, University of Toronto, President, Canadian Society of Palliative Care Physicians
Right now we have no way of being able to measure the quality of palliative care services that our patients have access to. By having minimal standards across the board throughout our country, we can essentially hold health authorities accountable by using evidence-based information tools, the latest and greatest from all of our research and all of our researchers, so that we're really holding ourselves to the highest possible level we possibly can to provide the very best for our patients.
7:15 p.m.
Senator, Quebec (Rougemont), ISG
Thank you, Dr. Kaya.
Dr. Viens, like me, you were in practice before MAID came into force, so you have surely used palliative sedation, one of the items in the palliative care tool box. I thought I detected a hint of disregard for the practice, given the somewhat disdainful way you talked about physicians plunging palliative patients into sedation.
Am I mistaken? If so, could you please explain what you meant?
7:15 p.m.
Family Physician , As an Individual
You are mistaken, because I did not in any way mean to take a disdainful tone.
Throughout my career in palliative care, I have had to use palliative sedation hundreds of times. When MAID came into force, health care professionals working in palliative care appeared not to approve of the practice at all, so people tended to talk about “continuous sedation”.
7:15 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
You're almost out of time, Mr. Viens, so please wrap up your comments, if you don't mind.
7:15 p.m.
Family Physician , As an Individual
Right now, I, personally, use palliative sedation when MAID is not possible. Palliative sedation will always have its place.
None of my patients has ever spontaneously chosen palliative sedation over MAID when given a choice between the two. Palliative sedation is an important medical tool, but I use it only when MAID cannot be provided to a patient.
7:15 p.m.
Liberal
7:15 p.m.
Stanley Kutcher Senator, Nova Scotia, ISG
Thank you, Mr. Chair.
I have two questions for Dr. Downar.
I will say them quickly and leave you to answer them.
The first is that every part of medicine—being a physician myself—has a balance between specialty and primary care. That's why we have primary, secondary and tertiary care. Not everybody with diabetes needs an endocrinologist for care.
My understanding is that much palliative care is provided by family physicians. Does every patient who needs palliative care require full-speciality palliative care from a palliative care physician or can a properly trained, empathic, primary care physician provide high-quality palliative care to many patients? That's the first question.
The second one is that, at the risk of confusing palliative care with MAID, there has been discussion that resources provided to provinces have been allocated to MAID instead of to palliative care. I've looked at the federal Library of Parliament data that we just got. Maybe we can put it on the record that federal funding for palliative care has increased substantially since 2017 to 2018. What's your understanding of how this money has been used?
7:15 p.m.
Critical Care and Palliative Care Physician, As an Individual
I'll answer your first question. Thank you very much, Senator Kutcher.
As you indicate, a large majority of end-of-life care, and palliative care as well, can be provided by non-specialists. I think that as the complexity of symptoms increases you should involve experts and specialists, as you do for any other problem such as complex diabetes or complex heart problems; you don't need a cardiologist or an endocrinologist unless they're complex. I think that's definitely the case. Certainly, for more complicated physical symptoms, I think you would definitely want to look at an expert and get an expert's involvement.
Unfortunately, when it comes to the main drivers of medical assistance in dying, it almost never relates to physical symptoms—or even less to psychological symptoms—but actually to this existential distress, which is something for which we have little or nothing to offer. That's why it's important to distinguish this, but really, to emphasize and bolster the palliative care sort of pyramid and make sure we have adequate specialist resources for those more complicated symptomatic cases is super important.
In terms of your second question, I'm very impressed that you read through the documents about where the funding is going. I'm glad somebody did. I think it's really important to emphasize that the money comes to the provinces and the provinces decide how it's spent, but there's never a sort of “earmarked” anything in the physicians' services budgets anywhere that “this goes to palliative care and MAID” and you have to fight over it. That's definitely not how it happens.
Some people use the same fee codes for the same activities, but as I said, it's not a zero-sum game. One does not come at the expense of the other. There is sometimes a global cap on physicians' services budgets, but it doesn't mean that MAID happens at the expense of palliative care, and certainly for people who are salaried and do both activities, they almost invariably do MAID in their sort of downtime or on weekends. There's really no suggestion, I think, or no reason to believe, that these resources are being repurposed.
That said, MAID is not the reason that palliative care is under-resourced in Canada. The reason that palliative care is under-resourced in Canada is that palliative care is under-resourced in Canada.
7:20 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Senator Kutcher.
We now go to Senator Dalphond for three minutes.
7:20 p.m.
Pierre Dalphond Senator, Quebec (De Lorimier), PSG
Thank you, Mr. Chair.
Dr. Viens, please keep in mind that I have three minutes, so I will keep my comments brief and I would ask you to do the same, although I realize you have many years of experience.
You brought up an argument often cited by MAID opponents: that the data provided by Health Canada were not reliable.
Do you have any recommendations on how to make the data more reliable? Dr. Downar did say, however, that the coroner's office in Ontario had confirmed the reliability of the figures provided by Health Canada.
7:20 p.m.
Family Physician , As an Individual
The data provided by Health Canada is correct. This refers only to investigative data on palliative care provided to patients prior to medical assistance in dying.
There should be a more precise definition of what palliative care is being referred to when asking if a patient has received palliative care. Is it ordinary care that can be provided by any family physician with some experience and minimal training, or is it more like second- or third-level palliative care such as that provided in hospices?
Personally, I have always answered in the affirmative when asked if the patient to whom I gave medical assistance in dying had received palliative care. Of course he always received it. He received it from his family doctor or from our palliative care team, which, incidentally, is the same team that provides medical assistance in dying. For our part, operationally, we do not differentiate between palliative care and medical assistance in dying.
My comment was mainly about the data on whether palliative care is used or not. The rest of the data is absolutely correct.
7:20 p.m.
Liberal
René Arseneault Liberal Madawaska—Restigouche, NB
Mr. Chair, I'd like to raise a point of order.
Dr. Downar mentioned that he had sent a brief to the committee, but I don't think we received it.
I just want to remind him to send it to us, if he hasn't yet.
7:20 p.m.
Critical Care and Palliative Care Physician, As an Individual
I sent it this morning. You may not have received it in time for the meeting.
7:20 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
As you know, the brief must be translated before it can be distributed.
Thank you, Mr. Arseneault and Dr. Downar.
Senator Wallin, the floor is yours for three minutes.
April 28th, 2022 / 7:20 p.m.
Pamela Wallin Senator, Saskatchewan, CSG
Thank you very much.
Our time is brief, so I have a quick question for Dr. Downar first, which is picking up on Dr. Viens' point that MAID is not driven by a lack of access to palliative care; they are part of a continuum. Would you describe it that way?
7:20 p.m.
Critical Care and Palliative Care Physician, As an Individual
I do see a difference between palliative care and medical assistance in dying, for a variety of reasons, and I think there are a lot of important members of the palliative care community who really feel distinctly uncomfortable with medical assistance in dying. I think it's important to keep a definitional distinction for that purpose.
I think that broadly grouping them under the category of end-of-life care is the most useful distinction. That avoids people having to identify with something with which they have a strong moral disagreement and therefore adopting a sort of peaceful co-existence, as exists in many parts of the world, where some people perform, some people do not, and some people include it as part of their care and others do not. That's what's been going on in Belgium and the Netherlands for years, and it's starting to happen in many parts of Canada too. I think that's probably our future.
7:25 p.m.
Senator, Saskatchewan, CSG
Thanks.
Then I'll get a brief comment from Dr. Viens. You started in your opening remarks to talk a bit about advance requests. Can you give us just a moment on that, particularly on the question of Alzheimer's? I think you started to comment and then time ran out.
7:25 p.m.
Family Physician , As an Individual
This is a question that will require far more than two minutes to answer.
7:25 p.m.
Family Physician , As an Individual
I'm just referring to the recent report of the Quebec National Assembly special commission. It contains I think the very basis of how we should consider advance directives to be included in the medical assistance in dying act.
The current position of the Select Committee on the Evolution of the Act Respecting End-of-Life Care in Quebec is that advanced directives should be reserved for patients who have been newly diagnosed with a cognitive neurodegenerative disease, such as Alzheimer's, and not in any other situation.
I think it's important to set the context. Doing this allows doctors who make a diagnosis of Alzheimer's in a patient to explain in detail what's going on, what the nature of the disease is, what's ahead, what the treatment options are, and so on.
The patient is then able to make an informed decision as to whether they want to risk one day becoming unable to decide their fate and spending the rest of their life in that situation, that kind of agony. This would allow doctors to have advance medical directives that are truly detailed and personalized when they are called upon, 10 years later, to carry out an advance request for medical assistance in dying for a patient who probably won't remember making it. Moreover, the patient would be unable to communicate with the doctor because the dementia would be well established.
It is imperative that the physician be able to rely on advance medical directives that truly reflect the patient's wishes, especially from the perspective of their existential suffering.
7:25 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you very much.
We'll complete this round with Senator Martin.