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.
Canadian Society of Palliative Care Physicians
This isn't something that our association has discussed. Certainly, our association supports access, so I can see that it might be a viable solution in some places.
Senior Nurse Advisor, Canadian Nurses Association
We all know that nurse practitioners are autonomous professionals and currently are prescribing medication. They have an expanded scope and are working in areas where they are sometimes the lead providers. In terms of access, we believe that this proposed model will enhance access and will enable teams to provide this service together.
That's our comment.
Senator, Quebec (De la Durantaye), C
Particularly in this enormous country that we live in, with a lot of rural areas and no physician access at all.... However, you're quite right that the Supreme Court ruling refers to “physician-assisted dying”, although the Quebec ruling through Bill 52 talks about “medical aid in dying”, which is a different term. It is, indeed, much broader. If you think about it, “medical aid in dying” is broader than physician-assisted dying, I suppose, if you want to dissect the language.
Vice-President, Medical Professionalism, Canadian Medical Association
However, in Quebec it is limited to physicians only.
Senior Nurse Advisor, Canadian Nurses Association
I just want to clarify that there's a role for nurses for Quebec in the assessment component. They're also part of the team that provides support, because they have the structure in place.
However, I agree that the administration of it is physician-led.
Senator, Quebec (De la Durantaye), C
Another issue that has come up in our discussions with previous witnesses has to do with advance directives. The Supreme Court didn't contemplate advance directives, and the debate in Quebec on Bill 52 was very conflicted on advance directives, which were actually dropped from the final draft of the bill.
However, again, the provincial-territorial expert advisory group recognized the roles of advance directives and that they vary across the country. They did recommend, though, that a patient's wishes to consent to physician-assisted dying in advance should be permitted through what they called a standardized patient declaration form, or a living will.
What is your impression of that recommendation?
Vice-President, Medical Professionalism, Canadian Medical Association
That's a very important issue. This is another one where our interpretation of the Carter decision did not include the ability to provide advance directives. We read it, and our constitutional lawyers read it, to indicate that it applied to someone who was capable at the time of request and at the time of the activity of assisted dying. It's not something that we consulted the membership on.
What I can tell you is that in real-life practice, putting advance directives into action is incredibly complex and difficult, because it's very hard to capture all of the nuances and the specifics of a very complicated medical condition and intervention. Even in the best of situations, physicians have a lot of difficulty actualizing an advance directive.
What our members have told us is that they see a lot of potential difficulties if we were to layer on the concept of providing advance directives with a very complex set of circumstances in this type of novel intervention, especially right out of the gate. It would, again, be one further level of complexity that would make it more difficult for a lot of physicians to participate and to actualize the assisted dying process.
Certainly it's not our official policy, but I would caution that it opens up another whole set of circumstances.
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
Thank you, Dr. Blackmer.
Before Senator Joyal asks his questions, I'm going to take the chair's prerogative and ask a question.
In the nurses' presentation, you were recommending that we have policies and procedures to ensure competency assessment throughout the journey. Dr. Branigan was talking about a worry that we could be prematurely hastening death as a result of some of the processes around physician-assisted dying.
Is there a concern that ensuring competency until the moment that assistance is given could hasten death because someone might want to make sure that they make that decision while they are deemed competent, yet could still be competent and could enjoy a quality of life for a number of months afterward? Might they be so afraid that they will not have their advance directive honoured that we would actually be encouraging them to die earlier?
I'm concerned about a difference that I'm hearing in the panel. Do you have thoughts on that?
Chief Executive Officer, Canadian Nurses Association
What we were referring to was that during this journey, which we believe is complex, there needs to be robust assessment and input from the team to ensure that when patients are seeking assisted dying, they have all the information to make a decision that is in their best interests and that they will periodically have the opportunity to reflect on that decision, because sometimes circumstances change. We wanted to ensure that there were mechanisms to ensure that patients would have the opportunity to revisit the decision they had made.
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
You do say that—to reconsider the decision—but that point is separate from competency assessment throughout the journey. Does that truly mean competent at the moment of death when assistance is given? Is that what you...?
Liberal
The Joint Chair (Mr. Robert Oliphant) Liberal Rob Oliphant
Okay. That was unclear. I think I was hearing elsewhere that you didn't want to hasten death unnecessarily. I just want to be clear on that.
Okay. Very good.
Senator Joyal.
Serge Joyal Senator, Quebec (Kennebec), Lib.
Dr. Forbes, I would like to come back to a statement you made in your opening remarks that is troubling to me.
You said that 30% of the physicians you have canvassed have answered that they would provide physician-assisted dying, which means that 70% won't. While the Supreme Court has stated very clearly that, according to section 7 of the charter, a person has a right to request assistance from a physician, you have to reconcile that with the freedom of thought, or the freedom of conscience, of a doctor or a physician under paragraph 2(b) of the charter. Which one prevails in such a case? Could you be very clear on what your position is in relation to a physician who would feel hurt in his or her conscience if he or she would be compelled to provide assistance in dying, and what the responsibility of that physician is in relation to advising the patient or referring the patient to a proper service or proper information so that the person could seek the support they need in these circumstances?
President, Canadian Medical Association
That is essentially one of the main issues we've been dealing with. I think it would be important to actually focus on what we feel are the responsibilities of the physicians. We feel that those physicians who are not willing to provide the service and who may feel that a referral is also against their moral beliefs do have responsibilities to advise the patient on all of their options—to have the conversation we talked about on all end-of-life options, including physician-assisted dying, and to make sure the patient has the information they need to access that service.
When you mentioned that only 30% of physicians are willing to provide the service, I think you have to look at the fact that we're expecting that less than 3% may actually choose this option. We have about 82,000 member physicians in the Canadian Medical Association, so you're actually talking about a large number of physicians. After that you're really talking about distribution and access to care in different regions. I think it helps to put it into perspective.
I know Dr. Blackmer wants to comment as well.
January 27th, 2016 / 5:55 p.m.
Vice-President, Medical Professionalism, Canadian Medical Association
I think it's absolutely critical to recognize that 30% represents 24,000 Canadian physicians. I can sit here today in front of this committee and guarantee that simply from a numbers perspective, access will not be an issue.
As Dr. Branigan has already indicated, it's about connecting the people who qualify for assisted dying with the providers who are willing to undertake assisted dying with a patient. The whole issue of connecting access with the right to conscientious objection is a false dichotomy. The two are not interrelated. In fact, we have a very small percentage of members who said they feel very conflicted about the obligation to refer; however, the entire rest of the profession says that even though they may not share that view, they will fight for the right of the others to not have mandatory referral.
In summary, if you have a very small percentage of the profession and a very small percentage of patients actually requesting assisted dying, that is not going to impact access in any way.
The final point I would make on that, which I think is critically important, is that no other jurisdiction in the world has mandatory effective referral. None of the jurisdictions that currently allow either assisted dying or euthanasia have mandatory effective referral, yet access is not a problem anywhere. I can guarantee, on behalf of the medical profession, that access will not be a problem in relation to respecting conscience rights. We still have work to do in rural and remote areas, but that's another issue.
Senator, Quebec (Kennebec), Lib.
Will that be part of the instructions or interpretation that you will provide to the medical profession in terms of the provincial colleges of doctors, which have the responsibility for déontologie and ethics, in relation to what the role is in relation to physician-assisted dying?
Vice-President, Medical Professionalism, Canadian Medical Association
They're very clear on our views on this issue, yes.
Senator, Quebec (Kennebec), Lib.
Thank you.
If I may, Mr. Chair, I have one very small question.
Senator, Quebec (Kennebec), Lib.
Dr. Blackmer, you made the statement that there is already a patchwork of directives among provinces. We had a witness earlier this week, Professor Hogg, who advised us that one way to alleviate that would be for the authority of the federal government—or a federal agency of some sort, yet to be defined—to establish equivalence of norms across Canada. In other words, elements of the service of course fall under provincial jurisdiction, but since it seems there is already a patchwork, we already have the problem and we already have to find a solution. This is not a theoretical situation. It is, according to your own statement today, a practical situation we face to maintain equality and universality of services across Canada.
Would you advise us that this is a way for us to go—to establish a national framework, and when there is a capacity for a province to intervene, that there be a measure of equivalence to make sure that Canadians are served equally all through the country?
Vice-President, Medical Professionalism, Canadian Medical Association
I think that's an approach we would support, yes.
Liberal
Julie Dabrusin Liberal Toronto—Danforth, ON
Thank you, Chair.
We've been talking a lot today about the issue of access, and particularly access in remote communities. Can you tell me a bit about the role of nurses and nurse practitioners in terms of the scope of the care they currently provide in remote areas?
Senior Nurse Advisor, Canadian Nurses Association
Currently we have over 4,000 nurse practitioners in Canada and we have 250,000 nurses. I don't have the numbers in remote and rural communities, but those two categories are present throughout the remote and rural areas.
They have access to teams. Sometimes they are virtual teams. Sometimes they serve in areas where they are the sole providers. Nurse practitioners have an expanded scope. They are able to provide diagnostics and management of conditions and have prescribing authority. Nurses in those communities do work under some medical directives, so their scope is expanded as well.
I hope I've answered your question around the rural and remote situation.
Liberal
Julie Dabrusin Liberal Toronto—Danforth, ON
Thank you.
We've heard a little bit of discussion about the use of telemedicine for nurses. I think it was referred to in the provincial and territorial report. Can you describe for us how that works?