Physician-Assisted Dying Committee on Jan. 27th, 2016

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

Thank you, Mr. Chair.

My question is to Dr. Branigan.

There is evidence from other jurisdictions that persons can be motivated to request euthanasia or assisted suicide by factors other than a medical condition—for example, victimization, social isolation, economic disadvantage, and so on.

You alluded briefly to the need for training, but I wondered if you might be able to comment on what kind of training physicians currently have to identify this wide range of factors.

[Dr. Monica Branigan]

Our palliative care training is woefully inadequate. At the University of Toronto, medical students get less than 16 hours in their whole curriculum. What kind of training have they had for exploring these kinds of requests? As a palliative care physician, I talk to patients about this at least once a week.

Absolutely, you're talking about the question of burden. If you look at burden, that is one of the more common reasons that requests for hastened death are granted, and burden is sometimes a perception of burden.

Other reasons that come up are not being able to live one's life in the way that one wants to, meaning loss of autonomy. A big reason is being unable to accept help in toileting. For many people, that is grievous and intolerable.

Regarding the other question, what I think you're getting at is whether somebody would potentially be granted the ability to hasten the end of their life because of poverty, for example. That, I think, would be part of the equation. We always look at how much support is available in the home, and that's a big part of the assessment.

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

To follow up on the issue of training, I think that there have been some who have come before this committee and, I would suggest, have framed this whole procedure of euthanasia or assisted suicide as a simple one, but there are many instances of people literally waking up in the middle of being euthanized, so in a lot of respects, it's a complex procedure.

I was wondering if you might be able to comment on that in the context of the need for training.

[Dr. Monica Branigan]

I don't think the actual procedure itself is that complex; I think the ability to respond compassionately to a request to hasten death is complex.

If you look at why people request euthanasia, it breaks down into four areas. It's often an expression of despair. As well, for some people it's a hypothetical exit plan, and that means in Oregon about 40% of people who get a prescription never use it, and they derive benefit from it. These kinds of requests also come along when someone is imminently dying. Then there is that group of people who persistently request and follow through, and in that group such things as burden and autonomy and dignity tend to be reasons much more common than pain or uncontrolled symptoms.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

I'll give you a little extra time because Dr. Forbes wanted to get in.

[Dr. Cindy Forbes]

Just for the information of the panel, I wanted to let you know that the Canadian Medical Association recognizes the need for physician education around physician-assisted dying, and we are currently developing educational programs for physicians. Dr. Branigan is actually an adviser.

We see two main aspects to these programs. One would be education for all physicians, so as a family physician, if I had a patient requesting physician-assisted dying, I would be able to have the early conversations and be able to access information and resources for the patient. The second part would be a more intensive training program for physicians who are willing to assist patients, and that would definitely go into some of the more complex issues, including the means and medication procedures involved as well.

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

Take another minute.

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

Dr. Branigan, when Maureen Taylor came before this committee yesterday, she disputed some statistics. She is from the provincial-territorial panel and she suggested that the statistics of somewhere in the neighbourhood of 15% to 30% of Canadians having access to palliative care were outdated, and, second, she also said that Canada is so vast geographically that palliative care really need not be part of the discussion surrounding assisted dying.

I wonder if you might be able to comment on those points.

[Dr. Monica Branigan]

The truth is we don't have adequate data to know what access to palliative care is. That's the truth. We do know from the latest report from the Canadian Cancer Society that 45% of cancer patients are not seen by palliative care practitioners in their last year of life, so I don't think there is too much doubt that access is a problem.

I'm sorry, but I've forgotten the rest of your—

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

Thank you, but I do need to go on. We've had an extra minute and a half.

Mr. Rankin is next.

[Murray Rankin, NDP, Victoria, BC]

Thank you very much.

I'd like to first ask the Canadian Medical Association this question.

In your materials, you talk about the need for Parliament to develop a pan-Canadian national approach, and you point out that seven provincial regulatory bodies have released draft or final guidelines, presumably from the colleges in the provinces.

It's a two-part question. First, are you content to leave it to the colleges to do this work, or do you think there is a role for Parliament in addressing these questions? In other words, can the doctors, as a self-governing profession, do the job, and if so, what about the uniformity we are hoping to achieve here if we do leave it to the regulatory bodies in each of the provinces?

[Dr. Jeff Blackmer]

Thank you very much. That's an extremely important question for the profession at the moment.

What we had hoped to see as the provinces developed these guidelines was a much higher degree of consistency among the various approaches. There is a national body that represents them, but we've certainly seen a diversity of views and a diversity of policies being developed. As I said, some are slightly different, while some are very substantively different.

We're very clear on the fact that if this is left at the provincial level, we will have a patchwork. We already have a patchwork, as I said. It's no longer a theoretical concern. It exists in reality now, and our members are telling us about their concerns. I have phone calls every day from people saying, “I live in this province. I think I am going to move to that province because I like their rules better and they coincide better with my own moral views.” It is not a theoretical issue anymore.

Because of that, we certainly would look for a very rigorous federal approach to try to make sure that we do have consistency from province to province on some of these very difficult issues to resolve some of these uncertainties.

[Murray Rankin, NDP, Victoria, BC]

Second, I very much appreciate your principles-based recommendations for a Canadian approach. In “Stage 2: Before undertaking assisted dying”, you call for a “second, independent consulting physician”.

I've heard from others that this second physician ought to be a specialist in the field—an oncologist in one case, or someone familiar with ALS, or perhaps a psychiatrist in another case. Would you subscribe to that idea? Would you agree that it ought to be...?

Is there a fear that two doctors in the same small town might see the world very differently, and one needs an outsider, perhaps a specialist, to intervene?

[Dr. Cindy Forbes]

I think the issue varies. If the first physician feels that it is complex, we've certainly suggested that they may wish to get a specialist referral, especially with the assessment of capacity when they aren't sure whether this patient is capable of consenting, so in some instances, having a regulation that it be a specialist would actually restrict access.

We feel that in the framework we put in place, we were very clear about what's expected of the two physicians. We feel that if those guidelines are followed, the second physician shouldn't necessarily have to be a specialist.

[Murray Rankin, NDP, Victoria, BC]

I'd like to ask a general question, perhaps for Dr. Branigan, perhaps for the CMA.

How would you feel about this service being provided at home for a patient who's gone through all of the steps you require, or that we will require, who wants to exercise this right at home? Do you see it only being done in a hospital setting?

[Dr. Monica Branigan]

I'm sure that many more patients will want this at home, surrounded by their family, rather than in an institution.

[Murray Rankin, NDP, Victoria, BC]

So you would have no medical difficulty with either route to that end?

[Dr. Monica Branigan]

As long as there was a willing provider in the home, absolutely. I think that's where people want to die.

[Murray Rankin, NDP, Victoria, BC]

Okay.

You both spoke about the proportionate waiting time issue. I'd like to ask you a little bit more about that.

Dr. Blackmer, I think you talked about legislative guidelines for the waiting time issue, yet I can see there's a vast difference, depending on the disease and the circumstance. You talked about a breast cancer patient with four weeks to live versus a 21-year-old.

How could one legislatively provide these guidelines? Isn't this something that ought to be left to the discretion of the physicians—subject, of course, to discipline by their self-governing profession?

[Dr. Jeff Blackmer]

Perhaps I'll try to address that first. It's an excellent point.

I think we'd like to see clarification on the need for some sort of a reflective waiting period. I have heard people in discussions say that it really should just be one doctor, and that five minutes after the request is made, the intervention should be available. There should be no opportunities for that sober second reflection or for further discussion with family and loved ones.

I think we'd like to see the principle become clear, but recognize that absolutely there will need to be room for decision-making between health care providers and patients, depending on the situation.

[Dr. Monica Branigan]

I agree with what Dr. Blackmer is saying. It's hard to just have a rigid waiting period that will be appropriate. I would support that.

[Murray Rankin, NDP, Victoria, BC]

Not specific rules—

[The Joint Chair (Mr. Robert Oliphant), Liberal, Rob Oliphant]

Thank you, Mr. Rankin.

I'll move now to Senator Seidman.

[Judith G. Seidman, Senator, Quebec (De la Durantaye), C]

Thank you, Chair.

I'd like to pursue Mr. Rankin's issue about uniform access.

You yourselves talked about a pan-Canadian approach. I'd like to know how all of you might respond to a recommendation that we heard yesterday from the provincial-territorial expert advisory group. Their recommendation to us was that regulated health care professionals, including registered nurses or physician assistants, should be able to provide physician-assisted dying under the direction of a physician or a nurse practitioner.

Might I have your impressions, from all three of your associations, about this proposal?

[Dr. Cindy Forbes]

To date, we've always assumed that there would be a team involved in the care of the patient, but our understanding of the Carter decision is that it's physician-assisted dying. That was our interpretation, so we've looked at it in that light. It is certainly within the realm of possibility that it could be expanded. We have not put that forward, or either supported or opposed it, but we could see that, for access purposes, there may be instances in isolated areas when it could it occur.