Evidence of meeting #6 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 request.
A video is available from Parliament.
9:15 p.m.
Bloc
Luc Thériault Bloc Montcalm, QC
Some witnesses have said that when they explained the various options available to their patients, the patients did not opt for solutions like advance requests.
What's your view of that?
9:15 p.m.
The Joint Chair Hon. Yonah Martin
Thank you. We have run out of time for that question.
Next we'll have Mr. MacGregor for five minutes.
9:15 p.m.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Thank you, Madam Co-Chair.
We heard from Dr. Gallagher in her opening statement that people are poor at anticipating what future medical conditions are like. Many witnesses have talked about the difficulty in determining consent.
Dr. Thorpe, our committee hasn't yet had your submission distributed to us, but we will look forward to reading it in detail. I appreciate your submitting it to our committee.
In your opening remarks, you urged our committee to really think very clearly about the guidelines that need to be set up, because people change and in some cases adapt to their new medical realities.
From a practical point of view in terms of what our committee may make recommendations on, if we permit advance requests for medical assistance in dying, for you as a practitioner, how often would you want to see someone be legislatively required to revisit their advance requests so that we can be sure that...? Is it every year, every couple of years, every three years? I don't know.
Is this something that we as a committee need to be checking in on so that people are being required to look at their advance requests to be sure this is something that they still want as time goes forward?
9:15 p.m.
Professor, University of Saskatchewan, As an Individual
Thanks. That's a good question.
I think it depends on what's wrong with a person. If we go with Jocelyn's idea that we only have these for someone who's had a diagnosis, if somebody has had a diagnosis of dementia, then they probably need to redo this every year, because they will have decline every year, and I think it should be done.
If one didn't have the requirement for having a diagnosis, which I actually wouldn't rule out.... I think some people have a family history of very severe dementia, and they might want to indicate what they would wish at, say, a chronic vegetative state. That might be a very different thing. That might be a five-year thing, but once one has a chronically degenerative condition, very frequently.... It's even quicker if you have something like Creutzfeldt-Jakob disease, which is very fast and progressive. I think there are a lot of these very context-specific things that we have to think very hard about.
I don't think it's not doable, and I'm not saying that we shouldn't have advance requests; I'm just saying that we have to really think about this and think about the practicalities for those of us who are going to end up seeing someone walking around not knowing their family members but still enjoying life. How are we going to do this? Are we going to hold them down? I can't see any of us doing this.
9:20 p.m.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
Would you, as a physician, appreciate a standardized type of request, specifying the bare minimum amount of detail that is required on a form and that also has to be accompanied by a personal note to better fill in the blanks that the form may present? Can you elaborate a bit more on that specific part?
9:20 p.m.
Professor, University of Saskatchewan, As an Individual
Absolutely, and you know what? Jocelyn talked about that. It's going to be really important to have exactly what that person's wishes are at that time.
It's also important to have that person meet with an informed person, a physician or a nurse, who knows what dementia looks like, and to have it documented that the person actually did have a full understanding of what they were talking about at the time. It may be that they may not fully understand what happens in 20 years, but at least we have some idea that they had a discussion with someone to think through all the issues. I think people very frequently sign things they don't understand. It's very common.
9:20 p.m.
NDP
Alistair MacGregor NDP Cowichan—Malahat—Langford, BC
On that concept of fully knowing what dementia looks like, we've often heard during this committee about the stigma that many people have—i.e., “Oh, my goodness, if I were to were to get a diagnosis of Alzheimer's, my life would essentially be over.” They look at the state of long-term care in Canada, and there's a very real fear there.
In your conversations, what have those been like for you in a practical sense, dealing with those very real questions and fears that people have?
9:20 p.m.
Professor, University of Saskatchewan, As an Individual
We talk about dementia always being terrible, but it's not always. We have people in our good nursing homes who are singing and dancing along. They can't recognize the families, but they're still having some quality of life. It's not what they anticipated, but they're still having quality of life. Those are the good ones.
We need to improve palliative care and long-term care facilities, absolutely, with more person-centred care, absolutely.
9:20 p.m.
The Joint Chair Hon. Yonah Martin
Thank you.
I'll turn this back to our co-chair for questions from the senators.
9:20 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Senator Martin.
With that, we'll begin with Senator Kutcher. These are three-minute rounds.
Go ahead, Senator.
9:20 p.m.
Senator, Nova Scotia, ISG
Thank you very much, Chair.
I'm going to share with you a case that I know. I'd like to hear from Dr. Boisvert and Dr. Thorpe on this.
Here's a person with stage 7 dementia. They are unable to self-toilet. They smear their feces on the wall or eat them. They do not recognize their family. They fall unless they're tied on to a chair. They can't eat solids because of the fear of choking. However, they get very good care. Every time they're dirty or soiled, they get cleaned up. They get dressed up. They spend their whole day sitting in front of a television set, laughing and singing, clapping at TV shows, and moving their body in time to the music.
Is the person suffering? How do you know if the person is suffering? If they had given you an advance request saying, “If I'm in this condition, I would like to have MAID”, would that assist you in that decision-making?
9:20 p.m.
Professor, University of Saskatchewan, As an Individual
It would certainly to help me to know what their thoughts were to start with, but I also don't think that the person would be able to necessarily predict whether they were suffering or not, because they're not there. That person does change. It's a person whose whole personal, emotional and physical experience does change.
It's a terrible care state to be in. At that point, what do you do? The practicalities will be really difficult. When somebody's this far gone, using supportive end-of-life comfort care measures might be much easier to institute than actively getting medications into that person, who is often, as I said before, not even taking in their drugs anymore. They're not even eating much anymore.
I still think this is going to be a difficult situation. There will be some situations—I've had patients with dementia who've had MAID—that will be doable, but many, like this one, will be very difficult for everyone involved, for the family members, the caregivers and the providers.
9:20 p.m.
Liberal
9:20 p.m.
Physician, As an Individual
Yes, certainly.
If that patient has completed an advance request for medical assistance in dying to avoid being in the kind of situation you described, then that patient is certainly suffering. If the conditions have been specified and the patient has reached that point, then we go ahead with medical assistance in dying, in accordance with that patient's wishes as specified in the advance request.
No one can say that patients, just because they can bop in time to the music, are happy. There is no such thing as a happy form of dementia; dementia exists and manifests itself in different ways. A person who was capable at the time they specified details in their advance request and who gave their free and informed consent does not want to experience that kind of situation.
9:25 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
Thank you, Dr. Boisvert.
I'm now going to give the floor to Senator Mégie for three minutes.
9:25 p.m.
Senator, Quebec (Rougemont), ISG
Thank you, Mr. Chair.
Thank you to the witnesses.
My first question is for Dr. Boisvert.
I'd like you to tell us more in connection with your answer to Mr. Thériault about the refusal to administer medical assistance in dying to a patient who had requested it.
And if an advance request had been authorized, what obstacles might have complicated the provision of medical assistance in dying, in your opinion?
9:25 p.m.
Physician, As an Individual
For your first question, about refusing to give medical assistance in dying, I'll just repeat that it's against the code of ethics to refuse to administer medical assistance in dying to a patient who has requested it, and who, in the assessment by practitioners, meets the eligibility criteria.
Currently, some people are not complying with their code of ethics with respect to medical assistance in dying. These people might behave in the same way with respect to advance requests. I can't tell you any more than that. Strictly speaking, it would be against the law if the Criminal Code were to include provisions establishing procedures that could be applied with respect to medical assistance in dying.
The second question, I believe, was about what appears to be a difficult issue.
9:25 p.m.
Senator, Quebec (Rougemont), ISG
I'd like to know what could constitute a barrier to the provision of medical assistance in dying.
9:25 p.m.
Physician, As an Individual
At the moment, we do not provide medical assistance in dying to all types of patients. And you can be sure that not all doctors or nurse practitioners in other provinces will administer medical assistance in dying when there have been advance requests.
Situations like this are not easy, because you're dealing with someone who is no longer the same person as the one who completed an advance request. It is indeed a completely different person, one whose billions of neurons have been destroyed by dementia or by the disease. It's no longer the same person.
The disease can manifest itself in different ways. People can become aggressive, or as Senator Kutcher described, move in time to the music. In any event, medical assistance in dying will be provided to them because that's what they wanted. It will not necessarily be easy, but it can be carried out in a manner that is perfectly correct.
9:25 p.m.
Senator, Quebec (Rougemont), ISG
Do I have a few seconds left, Mr. Chair?
9:25 p.m.
Liberal
The Joint Chair Liberal Marc Garneau
You have only 10 seconds, so I think we'll move on to the next person.
Thank you, Senator Mégie.
Senator Wallin, it's over to you for three minutes.