Evidence of meeting #6 for Physician-Assisted Dying in the 42nd Parliament, 1st Session. (The original version is on Parliament’s site, as are the minutes.) The winning word was nurses.
A video is available from Parliament.
NDP
Murray Rankin NDP Victoria, BC
That's the problem. I'm having trouble thinking of a situation, based on your testimony, that would meet that very stringent requirement of being irremediable.
President, Canadian Psychiatric Association
I can't make a definitive statement that nothing ever could. I don't believe that anyone could say that, but I share your difficulty in thinking of many, if any, that would.
NDP
Murray Rankin NDP Victoria, BC
I'd like to speak to the Canadian Pharmacists Association.
In your material, you talk about pharmacists and the point of access, and you say that the federal government should ensure that prescribers and pharmacists have access to the most appropriate drugs. What specifically are you suggesting the federal government would do? I can't see that being a federal matter. I don't understand what you're suggesting we would be able to achieve as a concrete recommendation.
Chair, Canadian Pharmacists Association
As I mentioned before, whatever protocols, treatment modalities, or therapeutic regimens are chosen, I caution the committee again to make sure that those drugs are available and accessible to Canadians and that the drugs are not subject to what we call “manufacturer backorder” or “manufacturer cannot supply”. In terms of the drug distribution channel for manufacturers, whatever we decide, thought and consideration have to be given that the availability of those regimens or drugs is not at the whim of a manufacturer or subject to other influences that could make them unavailable.
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
Thank you, Mr. Berardi.
Senator Nancy Ruth is next.
Nancy Ruth Senator, Ontario (Cluny), C
To the psychiatric association, you just said—and you testified to this in front of the external panel—that when a patient who has a mental illness requests physician-assisted death but it's for another condition, let's say cancer, the mental health people should be brought in to do an assessment.
I live in Toronto. Some of the folks I know with mental illness don't go to psychiatrists. They have their normal doctor, their family physician, treat them. Is this not so in other parts of Canada too?
President, Canadian Psychiatric Association
With regard to the latter part of the statement, about whether it is common practice, yes, I would say it's common practice in many areas. The primary care physician, the family physician, does play a key role in mental health provision.
However, in evaluating the thought processes that are going into a request like PAD, if there's a mental illness present, it's essential that people who have the required training be the ones who make that assessment.
I'll give you an example. I mentioned to your colleague that in the month prior to completed suicides, about one in five people have seen a mental health provider. In the same month, nearly half—about 45%, typically—have seen their primary care physician.
That's not to suggest that the primary care physician is not able to look at mental health needs. They can, but when we're doing complex risk assessments and complex assessments of what's behind someone's wish to die, we do need to bring in psychiatrists at that point.
Senator, Ontario (Cluny), C
Would that be done by Telehealth or a similar means in rural parts of Canada or in the north?
President, Canadian Psychiatric Association
Again, this is part of why we haven't come with a concrete recommendation on the best way for it to be done. It's because there may be jurisdictional logistics that determine that. In some areas, you may have psychiatrists available who could physically go to the patient, or you may have psychiatrists in some areas who aren't able to physically go.
In Ontario, for example, we have review board panels for capacity assessments that have been challenged. Those panels will be under provincial jurisdiction, rather than a local responsibility.
To answer your question, it might be a different mechanism in different places, depending on resources and needs.
Senator, Ontario (Cluny), C
But you're very clear that there needs to be a psychiatric assessment, for the pharmacists.
President, Canadian Psychiatric Association
Yes, or you'll miss things, potentially.
Senator, Ontario (Cluny), C
You mentioned in your presentation that there are some jurisdictions—the Netherlands, for example—where standard packages of drugs are available, as well as detailed technical guidelines. Given that you need to have the drugs approved and that they need to be readily available in all parts of Canada so that we don't run out of them like isotopes or something like that, are there any barriers to this being done in Canada? Is there any reason that these packages couldn't also be used here, as they are in other jurisdictions?
Director, Professional Affairs, Canadian Pharmacists Association
It's quite likely that some of the precedents that have been set in other jurisdictions, such as Oregon and the Netherlands, would be used here in Canada as well.
Typically, patients who consume these drugs in the home setting use long-acting barbiturate drugs, which is a class of drugs that hasn't been used very much in Canada in the last 20 years. Barbiturate drugs are used primarily for sleep.
There are some availability challenges with these drugs. For example, one of the drugs that's used is no longer marketed in Canada. Therefore, part of the process of considering which drugs would be used would be to look at what is currently available in Canada, and if certain drugs were not available, to look at how to make them available if they've been used successfully in other jurisdictions.
Director, Professional Affairs, Canadian Pharmacists Association
There is a process within Health Canada to provide increased access to drugs that are available internationally and to make them available in Canada through, for example, the special access program. However, if those drugs are deemed to be the most appropriate ones in this setting, there is a role for the federal government to make those drugs available.
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
I'd like to just ask one question to Dr. Gaind.
I am a minister in a church. I have done many funerals of people who have died with and from mental illness. If their deaths were all preventable, if nothing is irremediable or refractory, where is the gap? This is a genuine question. If you are saying virtually nothing is irremediable, yet I know of dozens and dozens of people who have died with and from mental illness, where is the gap?
Why have they died if it was possible to...? Where have you failed, or where have we failed?
President, Canadian Psychiatric Association
There are many facets to that question. In some cases, if the person has committed suicide, as I was mentioning, it often reflects that they haven't actually had access to psychiatric care. It's not to say all suicide is preventable—
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
Many of them that I know have actually.... Three of them have been in hospital, in care, and have committed suicide under the watch of a physician who was a psychiatrist.
President, Canadian Psychiatric Association
As I said, I'm not suggesting that we're saying all suicide is preventable if someone is seeing a psychiatrist. That's not what I was saying.
You're asking a bit about what the threshold is for defining something as irremediable. I don't know if that's a question for the profession to answer or for society to answer.
In some ways, there are concepts in law that talk about probability. My clinical background was as a psycho-oncologist at Princess Margaret Cancer Centre, and when patients have cancer, you can anticipate what the outcome may be, but you don't know 100% for sure in many cases. At what threshold do we say something is completely irremediable or not?
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
That's exactly what we're asking you.
I think I'm not going to get an answer, so that's okay.
President, Canadian Psychiatric Association
I don't have an answer for you on that right now.
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
Okay, we have a statement but not an answer. We have a statement from you that says nothing is irremediable, but not an answer on what the threshold could be.
President, Canadian Psychiatric Association
Actually, we were not saying that nothing is irremediable. That's not what we said.