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

[Dr. Carlo Berardi, Chair, Canadian Pharmacists Association]

Thank you, co-chairs, honourable members of Parliament, and senators, for the opportunity to present before this committee.

My name is Carlo Berardi. I'm a practising pharmacist in Sudbury, but I'm here today in my capacity as chair of the board of directors for the Canadian Pharmacists Association.

CPhA is the national voice for pharmacy in Canada, focused on advancing the health and well-being of Canadians through excellence in pharmacist care. Through our 10 provincial associations, we represent more than 20,000 pharmacists and pharmacy students across Canada.

I'm joined today by my colleague, Phil Emberley, who is also a practising pharmacist and the director of professional affairs with CPhA. We recognize that you all have an incredibly difficult task at hand, one that must balance the views and perspectives of various stakeholders, the public, and, most importantly, the patients. We are here today to speak to you about the role of pharmacists in physician-assisted dying and, conversely, the impact that physician-assisted dying could have on pharmacists.

Since the Supreme Court ruling almost a year ago, much of the public debate has focused on the role of physicians in assisted dying, and understandably so. However, physicians don't work alone. Rather, they are part of a larger system that relies on nurses, pharmacists, social workers, and other health care providers, each with their own scope of expertise and responsibility. While the Carter decision focused primarily on the role of doctors in providing end-of-life care, we have had the opportunity to reflect on the important role of pharmacists in both end-of-life care and assisted dying.

You have heard from various witnesses on the scope of the Carter decision and the extent to which other health care professionals should be involved in assisted dying. It is our opinion that regardless of how assisted dying is regulated in Canada, pharmacists will have a role to play.

Pharmacists are consistently rated as being among the most trusted professionals in Canada. Their accessibility and visibility within their communities also mean that pharmacists are often the first point of contact for patients who are looking for timely, evidence-based, and informed health information.

As a practising pharmacist, I know first-hand how the public relies on pharmacists for information on a wide variety of health issues, so it's quite likely that pharmacists will be asked to provide information on assisted dying to help in making an informed choice.

Over the past several months, CPhA has been consulting extensively with our members and with experts in the field in order to develop a policy position and framework to help inform governments as they themselves grapple with the issue. This consultation has included a national survey of pharmacists and pharmacy stakeholders, to which we received nearly 1,000 responses. The number of responses we received speaks to the high degree of interest within our profession.

We have also reviewed existing literature and looked at experiences in other jurisdictions that have legalized assisted dying to help inform our policy, and we will provide this information to the committee.

While we have not yet finalized our policy recommendation or a proposed framework for the role of pharmacists in assisted dying, we would like to highlight some of the areas that have consistently been raised.

As primary health providers, we are not surprised that assisted dying elicits various perspectives from within the profession, similar to what you have heard from our physician and nurse colleagues. We consistently heard that pharmacists care first and foremost about the health and well-being of their patients and about ensuring that their patients have access to the best possible care through their end-of-life journey. This means having access to high-quality palliative care, effective pain management, and assisted dying.

However, our consultations have also revealed some more practical considerations for pharmacists that we would like to bring forward today. While many of the concerns mirrored those of other health providers, including what you heard a short while ago from our colleagues at CMA and CNA, there are also issues that are unique and of particular relevance to pharmacists.

Regardless of the legislative framework that is put in place or of how the practice is regulated either federally or provincially, one of our primary concerns is ensuring the appropriateness and accessibility of drug therapies. There is no single drug that exists for the purpose of ending someone's life, so, as in the case of any other medication, we believe that the federal government must ensure that the prescribers and the pharmacists have access to the necessary drugs in order to provide the best possible care, including drugs for assisted dying.

In addition, we also recognize that existing jurisdictions that have legalized assisted dying have taken different approaches, each with different implications for how the actual practice is administered. While we have not finalized our policy and proposed framework on the role of pharmacists in assisted dying, we want to provide some context as to how some of the models could have an impact both on patient care and on the role and the responsibilities of pharmacists.

If we take Quebec as an example, assisted dying there is limited to medical aid in dying, which requires the physician to directly administer the lethal injection. The exact dosage and mix of drugs is set within the provincial framework, and while it's prepared by a hospital pharmacy, it is then administered by the physician in a hospital setting.

However, in parts of Europe and in the state of Oregon we've seen a broader approach that also allows for the oral ingestion of drugs in various settings, including in a home or community setting. In such cases, while physicians continue to play an important role as the prescribers, the role of pharmacists would expand significantly.

Beyond these issues that we feel are particularly relevant to pharmacists, we have also heard feedback from the profession that is consistent with that of other health providers. Pharmacists overwhelmingly support the inclusion of a protection-of-conscience provision in legislation. Like other professions, pharmacists feel strongly that they should not be obligated to participate in assisted dying if it is against their moral or religious convictions. In its ruling, the Supreme Court clearly stated that nothing in the declaration would compel physicians to provide or participate in assisted dying, and we believe that such protection must be extended to pharmacists as well.

While we also believe that patients have the right to receive unbiased information about assisted dying and how to access end-of-life care, like other health care professionals, pharmacists are divided on the obligation to refer someone to another pharmacist who is willing to fill a prescription for the purpose of assisted dying. Our priority remains ensuring patient access, so we encourage the government to examine options that could help facilitate referral while also protecting pharmacists' right to conscientious objection. Further to this, for those pharmacists who wish to participate, we strongly urge legislative frameworks that would limit the liability of health care professionals.

Regardless of the legislative framework, we want to ensure that pharmacists who are members of the interdisciplinary patient care team and also dispensers of lethal doses of medications are fully equipped to provide the necessary care to their patients. This means ensuring that there is effective collaboration between prescribing physicians and pharmacists and ensuring that pharmacists have access to appropriate information, support, and resources should they choose to participate in assisted dying.

Information about a patient's diagnosis and the purpose of the prescription, as well as confirmation of the patient's consent and confirmation that the patient has met all of the eligibility criteria, are key to ensuring appropriate dispensing and will enhance patient care at all points of contact in the system. We believe that this could help mitigate liability for all health providers involved.

We recognize that there is very little precedent to guide the government in addressing this important issue. This is a new area for pharmacists. Nevertheless, the pharmacist profession has the expertise in drug therapy, counselling patients on medications, and drug distribution to play an integral role in ensuring quality end-of-life care.

In conclusion, as this is a new and evolving practice, we believe that it will be critical to monitor and review the implementation of both federal and provincial legislation for years to come. We suggest that this be done through a national advisory panel of interdisciplinary health professionals that would include pharmacists.

In the coming weeks, we will be finalizing our policy and our proposed framework and we would be happy to share these with the committee.

We thank you for your time and we welcome any questions you might have.

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

Thank you, Mr. Berardi.

We'll now have Dr. Gaind or Ms. Hardy, please.

[Dr. K. Sonu Gaind, President, Canadian Psychiatric Association]

Thank you, Mr. Chair. I'll start for us.

On behalf of the Canadian Psychiatric Association, we'd like to thank the co-chairs and committee members for this opportunity to present to you on this important issue.

My name is Karandeep Sonu Gaind, and I'm president of the CPA. The CPA is the national voice for Canada's 4,700 psychiatrists and more than 900 psychiatric residents. Founded in 1951, the association is dedicated to promoting an environment that fosters excellence in clinical care, education, and research.

My remarks today will focus on specific issues related to mental illness that must be considered in any physician-assisted death framework. The CPA is actively engaged in developing a full position with a range of specific recommendations. My comments today are meant to raise key points for the committee to consider in its deliberations, but should not be construed as CPA's final position on this issue. That definitive position is still being developed.

I'll start with key issues that need to be taken into consideration when discussing terms like “irremediable”, “intolerable and enduring suffering”, and “capacity” in the context of mental illness.

The evaluation of what is intolerable and enduring suffering due to illness symptoms is affected by the severity of those symptoms and impairment and by the individual's perception of their experience. The subjective assessment of “intolerable” and the predictive assessment of “enduring” can both be affected by mental illness in particular ways.

Mental illnesses can affect cognition and impair insight and judgment. Symptoms of cognitive distortions common with clinical depression include negative expectations of the future; loss of hope; loss of expectation for improvement, even when there may be realistic hope for positive improvement; loss of cognitive flexibility; loss of future-oriented thought; and selective ruminations focused on the negative and minimizing or ignoring the positive. There are commonly distortions of a person's own sense of identity and role in the world, including feelings of excessive guilt and worthlessness or feeling like a burden to others.

When clinically depressed, people also have lower emotional resilience and are less capable of dealing with normal life stressors. They can experience even moderate levels of stress as being intolerable or overwhelming. While we are not at the point of being able to apply this clinically, increasingly research findings are suggesting that there are areas of the brain with altered functioning during times of severe depression that correlate with some of these cognitive changes.

In terms of what is “irremediable”, careful consideration needs to be given about what this means in the context of mental illness. Irremediable, of course, cannot simply mean incurable. Many conditions in psychiatry and medicine are considered chronic and not curable, but things may be done to remediate or improve the situation. Multiple treatment options exist typically for even the most severe instances of mental illness, whereby symptoms and suffering may be treated and reduced, even if not cured.

It is equally important and essential to remember that the person is more than the illness. Psychosocial factors play an enormous role in a person's illness experience, particularly so in many mental illnesses. For example, if you take an overly narrow view of assessing “irremediable” only in the context of potential symptom improvement through biomedical treatments in severe depression, you potentially ignore remediating or improving the person's experience by addressing such key factors as social isolation or poverty.

I'll make some comments on “capacity” now.

In medicine we consider four broad components when assessing capacity: the ability to make a choice, the ability to understand relevant information, the ability to appreciate the situation and the consequences of decisions, and the ability to manipulate information rationally. Even when persons with mental illness can express a choice and understand and recall information, their appreciation of the situation and of present and future expectations, as well as their ability to manipulate information rationally, can be affected by the cognitive distortions previously discussed.

I want to emphasize that none of this is to suggest that simply the presence of any mental illness alone impairs people's judgment and cognition, but in the PAD discussion, by definition, we are talking about the most severe situations, and in severe cases of mental illness, the risk of such cognitive distortion is, of course, higher. We think with our brains, not with our hearts or limbs.

All these issues speak directly to the court's concern about ensuring the person is not induced to take his or her life at a time of weakness. Apart from the actual suffering caused by symptoms, if cognitive distortions are present, these distortions risk undermining the person's decision-making process. In the court's consideration of factors of coercion or duress, it would be as if the mental illness is undermining the person's autonomy to make a decision free from the influence of cognitive distortions. It's this recursive effect of symptoms on the evaluative process, where the very symptoms of mental illness may interfere with people's evaluation of their mental illness and its present and future impact, that poses the challenge.

Finally, one other point bears consideration. In the context of the court's finding of loss of liberty if a person chooses to end his or her life prematurely because the person fears eventually becoming unable to take their life in the face of progressive physical incapacity and suffering, mental illnesses on their own very rarely, if ever, lead to such progressive and severe physical incapacity.

With that as a general background, and again emphasizing that the full CPA position is still being developed, there are a few guiding principles we can offer at this time.

First, when a psychiatric illness is present, in order to ensure that nuanced issues that could affect decision-making are properly assessed and to allow for time for potential remediation of symptoms and/or psychosocial factors, multiple assessors with suitable skill sets should do sequential assessments over a period of time. Our final position will reflect more specifics, and there may be varied mechanisms depending on jurisdictional needs and resources, but spreading the assessment over multiple suitable assessors who are aware of the potential impact of mental illnesses on cognition, capacity, etc., and also having sequential assessments are necessary safeguards.

Second, the concept of irremediable and intolerable and enduring suffering should not be exclusively focused on the biomedical condition but must be considered in the full context of the person's condition, including the potential impact of possible psychosocial interventions on suffering and symptoms.

Next, psychiatrists may choose not to be involved in the PAD process, consistent with what you have heard from other professional organizations. In such situations, patients requesting PAD should have access to information regarding available PAD resources and the referral processes, including psychiatric resources as required.

Finally, it is important to recognize that the term “treatment-resistant depression” or “treatment-resistant mental illness” in general does not define an illness that is irremediable. “Treatment-resistant” in this context is typically used to help guide the course of further treatment options using an evidence-based approach. This should be explicitly articulated in any PAD framework to avoid risking conflation of the terms “treatment-resistant” and “irremediable”.

I'd like to end by thanking the committee once again for your thoughtful consideration of these issues, and I'm happy to answer any questions that you may have.

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

Thank you very much, Doctor.

Go ahead, Madam Shanahan.

[Brenda Shanahan, Liberal, Châteauguay—Lacolle, QC]

Thank you, Mr. Chair.

This question is for the Canadian Pharmacists Association. Either one of you can answer.

I'd like to explore with you the relationship between the pharmacist's role and the doctor's role. Specifically, we're looking at how the process could take place. Then I'd like to talk about the canvassing you did of your members when you were assessing their position on this matter.

[Dr. Carlo Berardi]

To answer that question, it would be best to focus on the different types of models that could potentially be out there. If we're talking about a hospital-only setting, then the physician-pharmacist relationship would be much different from what it would be in an at-home setting for patients. It would be a much different type of relationship.

Pharmacists don't want to be involved in that determination of eligibility or competency, but certainly if a directive was given that involved the pharmacist's procurement of the medication, the directive would have to be clear in satisfying the eligibility and competency of the patient. That directive could not be misunderstood or misinterpreted, so that the pharmacist would be fully aware that the criteria or guidelines had been fully satisfied before an actual procurement or dispensing of medications could take place.

That would involve a lot of collaboration between the pharmacist and the physician, or maybe more than one physician, or maybe the medical team that would give the directive. In today's environment, pharmacists and physicians are collaborating on a whole range of therapeutics and options and treatment modalities for patients. Physician-pharmacist collaboration is not a new experience for our profession.

[Brenda Shanahan, Liberal, Châteauguay—Lacolle, QC]

Excellent.

You mentioned canvassing your members. What is the degree? We heard from the CMA that it was 30% of doctors. What's the number for pharmacists at this point?

[Dr. Phil Emberley, Director, Professional Affairs, Canadian Pharmacists Association]

Thank you for the question.

We did not specifically ask the question that the CMA mentioned earlier. We did ask the following questions, which I think are relevant to this discussion.

When we asked respondents to express their level of agreement with the statement “Pharmacists should be obligated to participate in assisted dying”, 70% of pharmacists either disagreed or strongly disagreed that pharmacists should be obligated, so there's fairly strong disagreement with that statement.

The other pertinent statement was “If a pharmacist does not wish to participate in any aspect of assisted dying, they must refer the patient and/or physician to another pharmacist who will fulfill the request.” We actually had 65% agree with the statement that they must refer.

[Brenda Shanahan, Liberal, Châteauguay—Lacolle, QC]

Thank you.

Can you talk to us a little bit without getting overly technical? We have heard, of course, there's an administration of a drug, and it can differ from person to person. How well equipped do you feel pharmacists are to make the professional judgment as to what is appropriate, given that they have not been doing this up until now?

[Dr. Carlo Berardi]

To answer your question, there are a couple of things.

First of all, there is no one single medication or one single prescription that will fit all. While I can't tell you exactly the types of medications that are used or the combinations, they certainly would be related to a lot of things. Weight, height, and body surface area would all be really relevant. Pharmacists today make those clinical or therapeutic decisions using those parameters every day. It's not that the type of practice would be new. There would be different training required for this aspect, of course, but that type of practice is not alien or foreign to pharmacists.

I would caution the committee that whatever protocol or treatment is decided on, it should ensure that those drugs are not subject to what is called “manufacturer backorder” or “manufacturer cannot supply”. That would be devastating.

We've heard about certain medications not being available in Canada, so I would caution the committee to ensure that, whatever protocols are designed, our drug system has the safety, the integrity, and the ability to supply those medications.

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

Mr. Albrecht is next.

[Harold Albrecht, Conservative, Kitchener—Conestoga, ON]

Thank you, Mr. Chair.

Thank you to our witnesses for being here tonight.

I was particularly encouraged to hear you, as professionals, openly declare your concerns about some of the subjective nature of the language that is being used—“irremediable”, “intolerable”, “enduring”. I think this underscores for us as committee members the severe nature of this topic that we're dealing with and how important it is for us to deal with it seriously and to move with extreme caution.

Over the last number of years, I've devoted a fair bit of my time to dealing with mental health issues and suicide prevention. I know that since 1991, there have been no fewer than 15 initiatives in Parliament to authorize physician-assisted suicide. All of these have been defeated. Parliament, in fact, in the last couple of years, has strongly supported some suicide prevention initiatives. Currently the Public Health Agency of Canada is undertaking the job of creating a federal framework for suicide prevention, which is a result of the passage of Bill C-300. In fact, today the Bell Let's Talk initiative is all over Twitter. I don't know how many thousands or millions of tweets have gone out.

Society is concerned about continuing their concerted efforts on suicide prevention. For me, then, it's something of a paradox that we have these initiatives to prevent suicide going on in our country and our health agency, yet here we are, looking at ways to give greater access to suicide.

It's quite clear that physician-assisted suicide is an irreversible act. We know from some of the mental health studies that have been done that people go up and down and that people's minds change over time. We also know that depression is by and large a treatable condition, and you pointed out in your testimony, Dr. Gaind, that there are varying degrees of success.

One of my concerns is that in terms of giving access to people who may be suffering with mental health issues or depression, what additional safeguards should this committee be looking at to make sure we are protecting some of our most vulnerable at the most vulnerable times in their lives?

[Dr. K. Sonu Gaind]

Thank you for your very considered question.

You know, it is a challenging issue to differentiate, when we're talking about the death of a person, what leads to that death. When we're talking about physician-assisted death or suicide prevention initiatives, it can seem that they're at odds with each other. However, there are some differences that I think are helpful to elucidate.

I'll get to the question you asked about some of the particular safeguards we need, because that actually comes back to what I was discussing in the comments—

[Harold Albrecht, Conservative, Kitchener—Conestoga, ON]

We have a small amount of time, so I'd appreciate it if you answered that last part first.

[Dr. K. Sonu Gaind]

Okay.

Both lead to the patient's death. That's true. However, one way of looking at it would be that suicide, in our suicide prevention initiatives, occurs when somebody has a desire to die. In physician-assisted death, the patient is suffering with some sort of illness, and they have a wish to stop living with suffering. It's the suffering component that is one differentiation.

When people have wishes for suicide or even have just clinical depression, they very often are unable to even articulate what might be leading to the feelings of depression. You have people who will say, “I shouldn't be feeling depressed, but I can't stop feeling this way.”

In terms of the evaluative process, this is why we are suggesting that you need people who are properly trained in trying to understand what is leading to the person making the decision. It is the decisional process that is key, not the outcome of it.

[Harold Albrecht, Conservative, Kitchener—Conestoga, ON]

Just to follow up on the point of conscience rights, you point out that the Canadian Psychiatric Association affirms the right of physicians not to participate if they choose not to. In fact, the Supreme Court has confirmed that physicians cannot be forced to provide assistance to an individual who is seeking assistance to die. You agree, and the CMA agrees. I would also point out, as Dr. Blackmer pointed out today, that currently no other jurisdiction that allows euthanasia or assisted suicide imposes a legal duty on physicians who conscientiously object to make referrals for physician-assisted suicide.

How important is that measure of conscience rights protection? How important is it that we include that?

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

I'm sorry, you've run out the five minutes. If you want to provide a written answer, that would be okay.

Madame Sansoucy is next.

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

Thank you, Mr. Chair. I will share my time with my colleague Murray Rankin.

I want to thank the witnesses for their presentations.

The experts we have heard from so far agree that oversight mechanisms are essential to ensure the protection of vulnerable individuals. At what point in the physician-assisted dying process do you think that oversight should be provided? Would it be before the person receives assistance to die, or would the experience be analyzed only after the fact?

[Dr. K. Sonu Gaind]

I want to make sure I understand the question properly. Are you asking at what point in the evaluative process should a psychiatrist start getting involved?

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

Yes, exactly.

[Dr. K. Sonu Gaind]

If there is a mental illness present, then this would apply whether the person is applying for PAD on the grounds of mental illness or whether they're applying on the grounds of a physical illness when they also have a mental illness. We feel that the psychiatrist needs to be involved to do a proper assessment as soon as the request is made.

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

When it comes to the decisions we will have to make over the next few months, we are being asked to establish pan-Canadian oversight mechanisms. The goal is to ensure that everything is taking place according to the rules, so that vulnerable individuals can give their consent in a truly informed way.

Should those oversight mechanisms be established before the individual even receives assistance to die? Do you instead believe that the process does not make that possible and that only the analysis of various situations will enable us to do an evaluation?

[Dr. K. Sonu Gaind]

I think your question actually speaks as well to the idea of patients having access to necessary treatment options even prior to making or requesting this decision. We know that is a huge problem with mental illness. The Canadian Mental Health Commission tells us that only about one in three Canadians who have mental illness or mental health-related problems get help for them, and for children and adolescents it's closer to one in four. I know that patients committing suicide is a different discussion, but even there we know that a only significant minority of them have seen a mental health professional in the past month. It's only about one in five.

In terms of what you're asking, this involvement should not be seen as the end point. We actually need to get involved much earlier to help people with these mental illness-related issues, and that may remediate suffering far before they get to the point of a request.

[Murray Rankin, NDP, Victoria, BC]

Dr. Gaind, if I may, you said that we should not conflate two important terms, the “irremediable”, which is the test in Carter, and “treatment-resistant depression”. I'm trying to understand. I can't think of a scenario in which a purely mental condition could meet the criteria in Carter. You say we shouldn't conflate those two terms. Are there irremediable psychiatric conditions that you can suggest that would meet the test? Are there stand-alone psychiatric illnesses, not biophysical ones, that would meet the test of being irremediable?

[Dr. K. Sonu Gaind]

As I mentioned, in the vast majority of cases and even in the most severe situations, something can be done to attempt to ameliorate. Failing all of that, it is conceivable that there could be an illness that's irremediable. Honestly, that would have to be assessed on a case-by-case basis. We're suggesting that the thinking process behind the patient making this request needs to be teased apart very carefully, because while they have a perception of something being irremediable, it may not actually be irremediable.