Physician-Assisted Dying Committee on Feb. 3rd, 2016

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Thank you very much.

Committee members, we have three panels, so would you be very clear in to whom you're directing your question.

Monsieur Arseneault.

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

I have a question for Dr. Davies. It's about age.

My question will be short. It has to do with minors.

How does the determination of a child's capacity to make a decision about their treatment differ from the determination of an adult's capacity to make the same decision?

[Dr. Dawn Davies]

Basically, in assessing the capacity of a minor person, we are trying to establish that they can have a full understanding of the information, and that they can process all the different alternatives available to them and make a decision that is reproducible if we have the same conversation with them again. What we're trying to establish is that they have an adult level of maturity and reasoning.

I think the difficulty is that the younger the child is, the more there are issues that may be at play in terms of trying to please others, including their parents and sometimes their religious and spiritual advisers, and they may even have beliefs about what is good for their family or what will be good for their siblings, for example. I think this is the reason that when it comes down to a life-and-death decision it's very often referred to the court, because those sorts of things are not clear. I think health care teams often want to refer to a higher authority for that decision to be made if the child is at risk of losing their life.

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

Thank you.

I was very glad to see that, in your brief, you mentioned the fact that, in the Carter decision, the court responded to the factual circumstances in the case and that the decision leaves the door open, as other witnesses have told us, to other possibilities.

I'd like to come back to the issue of age. In your profession of pediatrics, is there any consensus, at least in terms of a minimum age at which there is no doubt in determining that a child cannot give free and informed consent?

[Dr. Dawn Davies]

I don't think there is any consensus. Even across provincial jurisdictions, the age of consent varies greatly, from 14 to 18. I think capacity really comes down to the individual patient, with the individual question that's being asked of them.

In general, the less weighty the outcome of the decision, the more we allow the minor to play a role in that decision. For example, for a very young child, it may be asking which arm they would like their intravenous started in because the risk of harm is so low. However, a child not wanting potentially life-saving chemotherapy if they have a good prognosis or not wanting any further treatment if they have just suffered from a terrible car accident, for example, are the cases that are much more difficult to assess.

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

I'd like to stay on the same subject.

During your career, have you ever had to deal with a case where a very young child was in a serious accident and, as a result, sustained major injuries and had to decide whether or not to accept medical treatment? Have you ever had to consider or assess such a child's free and informed consent? If so, how old were they?

[Dr. Dawn Davies]

We had a case where it was a catastrophic accident. The teen in question was 17 years of age, so he qualified as a child at the beginning of the illness. Without saying too much more for the sake of confidentiality, a decision was made to treat that child in the immediate time after his accident despite his opposition.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Mr. Cooper.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

My question is directed to Dr. Rajji.

Dr. Rajji, from your experience, do all GPs have the training necessary to diagnose psychiatric conditions?

[Dr. Tarek Rajji]

By training, yes. That's part of the training for all GPs; they can make a diagnosis of a psychiatric condition. Sometimes when it's not a straightforward psychiatric condition, they may refer the individual for a consultation.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

How do you know if it's straightforward or not straightforward? Could you explain that?

[Dr. Tarek Rajji]

By straightforward, I mean following the way that we make a diagnosis. Clinically, there is a textbook where there's very clear criteria about how to make a diagnosis of a major depressive disorder or schizophrenia. When the presentation is not consistent with one of the criteria or the set of criteria, what we call the differential diagnosis is complex. When it's not clear that this was a depressive episode with psychosis or schizophrenia, then a referral is typically made for diagnostic clarification. That's when the clinical presentation does not fit in one category, a simple category.

[Michael Cooper, Conservative, St. Albert—Edmonton, AB]

The College of Physicians and Surgeons of Nova Scotia recently issued a standard of practice, and it provides that where the grievous and irremediable condition is a mental illness, either the first or second physician must be a psychiatrist.

My question for you would be in terms of dealing with a situation where, for example, there may be a grievous and irremediable condition that isn't a mental condition, but the person suffers from some sort of psychiatric condition which goes to the question of capacity. In those situations, is a psychiatric opinion necessary? Also, would a GP, for example, have the ability to, I guess, tease out the issue of a grievous and irremediable condition from that of a psychiatric condition, which may be the underlying motivation for the request?

[Dr. Tarek Rajji]

That's a great question. We also discussed that at our panel at CAMH.

I think it's critical to have a comprehensive capacity assessment for someone who has a mental illness but is suffering from a non-mental illness which could be the grievous and irremediable condition. As you are suggesting, I think it would be critical to evaluate whether the request for PAD, for example, is being driven by the mental illness itself or the view of their physical illness as influenced by the mental illness.

That's something, as psychiatrists, we engage in even now with different types of decisions. For example, when one of my patients has a chronic mental illness and they develop cancer, let's say, the oncologist would consult me to see if the decisions being made around the cancer treatment are influenced by the comorbid mental illness of schizophrenia, and how much the refusal or acceptance of a treatment is influenced by the cognitive distortions or beliefs that are driven by the mental illness.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Mr. Rankin.

[Murray Rankin, NDP, Victoria, BC]

Ms. Sansoucy will ask the first question.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Mr. Chair, I'm going to share my time with Mr. Rankin.

I'd like to thank the witnesses for their presentations. My question is for the Centre for Addiction and Mental Health representatives.

Mr. Lemmens told us that, in his view, the request should be considered by a committee made up of four members. Other witnesses told us—

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Could I ask you to stop for a second, please. Apparently the translation is not working. I have paused the time.

[Brigitte Sansoucy, NDP, Saint-Hyacinthe—Bagot, QC]

Thank you, Mr. Chair.

My question is for the Centre for Addiction and Mental Health representatives.

Mr. Lemmens told us that, in his view, the patient's request should be considered by a committee made up of four people. Other witnesses told us that a physician should be involved, some said two physicians, others said one physician and one psychiatrist, and others still said that a judge should be involved.

You told us that the request should be considered by a panel. I'd like you to tell us who should sit on that panel, as well as whether that component should, instead, come under the provincial and territorial legislation that will flow from our decision at the federal level.

[Dr. Tarek Rajji]

Thank you for the question. I will address the issue of the participation of a psychiatrist in these committees, and maybe Kristin can also talk about other potential members of such committees. It's also something we discussed in our panel at CAMH.

For individuals who don't have a mental illness before they develop a physical one that is an irremediable and grievous illness, I don't think it is always necessary to have a psychiatrist as part of the panel. However, many of the individuals who develop a terminal illness will develop a new mental illness, in the form of major depression or sometimes in the form of a psychosis. If there is a suspicion by the primary treatment team that there is a psychiatric condition that either happened before the physical illness or after the physical illness, I think engaging a psychiatrist at that level and as part of the panel would be important. Again, this is related to my previous answer about assessing extensively and in depth the issue of capacity.

[Kristin Taylor, Vice-President, Legal Services, Centre for Addiction and Mental Health]

With respect to the team that would be involved in the decision-making along with the patient to see whether or not the criteria were met, I think my friend has addressed that.

Where we would consider a panel or a board, such as the Consent and Capacity Board here in Ontario, would be where decision-making was required to be appealed, where the patient who was making the request was refused by the clinical team, the advisory team that was in place. It would be a place to go where the issues or the point of contention could be heard and properly addressed. As to the make-up of that committee, here in Ontario we have a psychiatrist or a medical practitioner, a layperson, as well as a lawyer. The combination seems to make sense. The competencies of that tribunal could certainly address these types of issues, although they are extremely complex and certainly new to that board.

The other aspects...perhaps if it's not an appeal, but there are certainly issues that come up in the context of the process itself, we would look to that board or that tribunal as well.

[Murray Rankin, NDP, Victoria, BC]

Thank you.

I would like to build on what my colleague asked you in regard to the Centre for Addiction and Mental Health. It's the same question, I suppose, but in a different way.

Ontario has the Consent and Capacity Board, as you referenced, as a review mechanism, but the only other province or territory that has a similar one is Yukon. I'm just wondering what you would suggest, what alternatives might provide similar safeguards elsewhere in Canada.

Also, are you suggesting that we create a board federally so that we have consistency, or leave this to the provinces and territories?

[Kristin Taylor]

To answer the first part of your question, I believe all provinces and territories do have health profession appeal boards of some sort. Whether or not it's a consent and capacity board, there are health appeal boards where decisions or issues that come up in the clinical setting or health care setting would go. I don't have my jurisdictional chart on that, but that's where I would look if there isn't a tribunal or a board specific to the mental health in the consent and capacity aspects.

[The Joint Chair, Hon. Kelvin Kenneth Ogilvie]

Could you sum up quickly, please.

[Kristin Taylor]

I missed the second part of the question.