Thank you very much.
Thanks for the wonderful presentations I've heard so far.
I'd like to say I'm a geriatric psychiatrist. I see and work with people with dementia. I very much agree with many of these comments about personhood and developing environments where people can live productive and quality lives, even in dementia.
I think it is very clear that most people I know do want to have access to advance requests for MAID. I also think this is going to be really challenging. We're going to have to really think about those guidelines and how we're going to do this.
First of all, people really do change. I see people in hospital with my consultation service who years ago made an advance directive that is often not what they want anymore. They say, “That was then. This is now.”
People change. People don't necessarily understand what they adapt to over time, which is what Dr. Gallagher spoke to. Many really do change, and they adapt to stages in their lives, such as dementia, that they wouldn't have expected before.
These people are not necessarily the same people who asked for this. I think what we do in real life is look at balancing the current person with all of their needs. Somebody with a dementing process needs a lot of help with what they previously wanted. It's a balance. That balance is often discussed within a mixed group of people who then really think about all the issues that have to be thought about in making a very complex decision.
Practically speaking, I think in some cases it's going to be fairly straightforward to approve an advance request if a person still has some ability to say what they want. I mentioned that I've seen close to 700 MAID assessments. I am a MAID assessor and provider. Many of my patients with dementia in early stages do still have some ability to say what they want. Some of them do talk about wanting to have access to MAID. When they're in that early stage, even if they don't have fully informed consent, they may have assent. Those ones, I think, will be the ones we can deal with.
There are people who are in a chronic vegetative state at the end. They may not be suffering anymore, yet we will also find those reasonably doable for us as providers. We will find that we feel we can live with this.
The problem comes in people who have this gradual loss of capacity and insight into the dementia. My patients often say, “Actually, I don't feel so bad anymore. I'm not even sure I have dementia anymore”, as they progress. They may enjoy their environment. They no longer focus on developing dementia, because they don't really know they have it anymore. Those will be very difficult for us to deal with, as would those who develop a lot of agitation and resistance. It's hard to even get them to take their medications, let alone large amounts of oral medications for MAID, or get an IV started for MAID. Those will be highly difficult, and this would be highly traumatic to both family members and care providers.
I have a number of suggestions, and I put them in my written report. I think that in straightforward situations, such as when a person is making a suggestion consistently that they do wish to die, as will happen sometimes, or when a person is in a chronically vegetative state and their advance request is sufficiently detailed to support the situation, these requests could be approved by the usual trained and objective MAID assessors.
There are, however, going to be far more complex situations in which there is no consistent communication from a person saying they wish to die, or there is a lot of conflict among family members about whether the advance request was really going to be consistent in the current situation. In these cases, I think there needs to be a very different process with consultations with some of us, such as geriatric psychiatrists—as is my practice—a geriatrician, psychologists and so on. I would like to see evidence of ongoing, significant suffering, and no evidence that the person is actually consistently enjoying life. If a person is consistently enjoying life and enjoying activities, I would feel very uncomfortable with that as a MAID provider. I would like to see no resistance of any kind to the MAID assessment or provision, with people trying not to have the IV started or to take oral medications. I don't think any of us would feel comfortable then.
I think what this means is that we need interactive meetings among the care team, family members, health proxies and MAID assessors and that we work through this. Maybe there is an ethics issue there. Maybe there are a number of people, not just one or two, making these complex decisions. Maybe social work is there to help with counselling of family members who are very distressed.
I will just tell you that we do have a waiver of final consent. I've had two daughters sobbing in talking about this waiver, because they say they would feel like they would be killing their father. Those patients who have had conflictual relationships with family members are going to be the most distressed by this. There also needs to be an appropriately constituted end-of-life committee that could look at these complex cases. These are going to be really hard, and we're going to have a lot of discussion about this.
That's what I'm going to say. I'm sorry. It's very practical. I'm not going to be able to tell you all of the details in the other countries. I'm just talking to you about myself as a geriatric psychiatrist and someone who sees patients day in and day out. I wanted to talk about those practical aspects.
Thank you for having me.