Medical Assistance in Dying Committee on May 9th, 2022

[Dr. Lilian Thorpe]

No, the longer the time is between a request and the actual event, the harder it is to anticipate how one feels and how one interacts with the world.

I think it's possible to have an informed consent when it's for a very short period of time, but the longer the time gets, the more you change. I think it would be very hard to have informed consent. I think this will become collaborative decision-making. I don't think it's as simple as just taking what somebody describes they might have wanted and what their suffering would be, then having everybody being able to act on it. I think it would be really complicated.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Dr. Boisvert, that's a good segue over to you because of that patient you described who has Alzheimer's.

Wouldn't she have been able to provide you with informed consent and not be in this situation she is now in the scenario I just put forward?

[The Joint Chair, Hon. Yonah Martin]

Go ahead, Dr. Boisvert.

[Dr. Laurent Boisvert]

When I met the patient, she was certainly fully capable of describing what she wanted to experience and what she did not. She was able to explain it clearly.

If the patient had been able to complete an advance request, we would have entered these details. The name of the proxy in the event of the patient's incapacity would also have been entered. This third party would have been responsible for triggering the procedure, meaning to go ahead with medical assistance in dying, in accordance with the criteria already specified by the patient when she was still capable of doing so. The care team, together with the third party, would look at the facts and the assessment, as Dr. Downie explained, and we would then proceed with medical assistance in dying.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

In that scenario, then, Dr. Boisvert, who would make the decision with respect to whether or not the criteria had been met?

[The Joint Chair, Hon. Yonah Martin]

Dr. Boisvert, you have about 30 seconds.

[Dr. Laurent Boisvert]

The third party is part of the procedure and is aware of the criteria specified by the patient for triggering the procedure. However, it is up to the clinicians, meaning the two doctors, because we have continued with the same approach, to establish whether the criteria have been met and whether the request is admissible. The clinicians make the decision.

[James Maloney, Liberal, Etobicoke—Lakeshore, ON]

Thank you.

[The Joint Chair, Hon. Yonah Martin]

Thank you.

Next we'll have Monsieur Thériault for five minutes.

[Luc Thériault, Bloc, Montcalm, QC]

Dr. Boisvert, thank you for having presented these two cases.

They clearly illustrate the situations that patients and doctors encounter.

Some witnesses told us that it was virtually impossible to have informed judgment when the goal is to make a decision several years in advance.

What's your view of this?

[Dr. Laurent Boisvert]

I don't think it's virtually impossible for people who are capable, who are aware of the situation in which they are making the decision, and who know the reasons why they are making that decision.

They need to specify the criteria and the clinical circumstances that will determine when it will happen. People go through this process in a free and informed way, knowing full well where things are headed.

[Luc Thériault, Bloc, Montcalm, QC]

Is a prior diagnosis essential, Dr. Boisvert?

[Dr. Laurent Boisvert]

I fully agree with Dr. Downie on this. An advance request for medical assistance in dying should only be possible once the patient has had a confirmed diagnosis of neurocognitive disorders or dementia that will definitely be harmful to the patient's capacity as time goes by. So a diagnosis must have been confirmed for a person to be able to make an advance request.

[Luc Thériault, Bloc, Montcalm, QC]

Are requests for medical assistance in dying strictly limited to cases of degenerative neurocognitive diseases?

[Dr. Laurent Boisvert]

Advance requests are made essentially because the patients know they are going to lose their ability to express their wishes one day or another because of their illness. And yes, it's for degenerative neurocognitive disorders.

However, other diagnoses may be involved. Let's, for example, look at Parkinson's disease, which is a degenerative neurological disorder, but can lead to cognitive problems. It's much less frequent in cases of amyotrophic lateral sclerosis and multiple sclerosis, which generally do not have a cognitive impact on patients.

[Luc Thériault, Bloc, Montcalm, QC]

So it could not cover things like strokes or aneurysms, which could create a disability or incapacity.

Could these medical issues be addressed by means of advance medical directives?

[Dr. Laurent Boisvert]

Healthy people would not be able to say that they would like to have medical assistance in dying if they were to have a stroke.

[Luc Thériault, Bloc, Montcalm, QC]

At the moment, people can make an advance medical request to specify, for example, that they do not want to be resuscitated if they have a stroke or cardiac arrest. People might wish to avoid the risk of sequelae stemming from such an event.

That exists already, doesn't it?

[Dr. Laurent Boisvert]

Advance medical directives in Quebec already cover cases like that. However, the mechanism is completely different, because the person is asking not to receive treatment.

For an advance request for medical assistance in dying, they are instead asking to receive this assistance once certain conditions have been met.

[Luc Thériault, Bloc, Montcalm, QC]

As soon as a patient is in a terminal phase, whether because they are suffering from Alzheimer's disease or dementia, and are curled up on their bed, could we consider that palliative care, which is after all a form of care, is a form of aggressive therapy because we would not be complying with the patient's request, and not doing what they have asked for?

[Dr. Laurent Boisvert]

Are you asking about a case in which the patient has made an advance request for medical assistance in dying and where we did not provide it?

[Luc Thériault, Bloc, Montcalm, QC]

Yes, that's right.

[Dr. Laurent Boisvert]

In a case like that, it would be more than a matter of aggressive therapy. As I mentioned earlier in discussing measures, measures are not necessarily safeguards. The advance request for medical assistance in dying is binding and cannot be challenged. If we were not to comply, that would be more than aggressive therapy.

[Luc Thériault, Bloc, Montcalm, QC]

So the fact that it is binding is crucial.

[Dr. Laurent Boisvert]

It's crucial.