Medical Assistance in Dying (MAiD)

What the pharmacist needs to know

Scenario

• You are on duty at a community pharmacy in Brantford, busy working through a couple of discharge prescriptions that were faxed over by the Brantford General Hospital.

• Your thoughts are interrupted by the technician, a physician is on the line to give a verbal prescription.

• The local physician tells you that he intends to write a prescription for a lethal dose of propofol to end a patient's life.

• Your mind quickly get overwhelmed with various

thoughts….

Scenario

• Situations such as this already occur in many countries and more recently in provinces across Canada.

• These raise a number of important considerations for pharmacists, including patient counseling issues, legal requirements, moral and ethical concerns, and possible consequences for refusing to dispense the medication.

• So far the major focus has been physicians and patients. However, in most cases a pharmacist plays a large role in Medical Assistance in Dying.

Lessons Learned • My Values:

• What do I feel about assisted dying? • Where do my feelings come from? • Would I want this option for myself, my

family, my patients? • What are my fears and hopes? • If a patient approach you about MAID, how

would I respond? • Other people’s values • Legal framework and eligibility criteria • Organizational response

MOVING FORWARD

UNDERSTAND

Yourself

The facts about MAID

ACT WITH

Integrity

Compassion

CONNECT TO

Your values

The patient story

Your resources

BILL C-14: MEDICAL ASSISTANCE IN DYING (MAID)

Who is eligible?

• mentally competent adults (18yo)

• eligible for health services funding in Canada

• grievous and irremediable medial condition

• be capable to make informed decision considering all options, including palliative care

• provide voluntary consent (through written request and at administration)

• NOT included: non-terminal conditions, mature minors, substitute decision-making and advance directives

“Grievous and Irremediable Medical Condition”?

• serious and incurable illness, disease or disability

• an advanced state of irreversible decline in capability

• that illness, disease, disability or state of decline causes patient enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable and

• natural death is reasonably foreseeable; does not require a prognosis of a specific length of time

WHO CAN ADMINISTER?

• MD, NP, Patient (self-administration)

• Permits conscientious objection, emphasizes obligation for effective referral

College of Physician and Surgeons of Ontario (CPSO)

• Outlines Bill C-14 requirements and reiterates eligibility criteria

• Emphasizes compassionate response to requests

• Careful management of conscientious objection, specifically effective referral

• Provides process map

• No specific direction re: drug protocol, assessment process, etc.

Lessons Learned: CPSO

• Good record keeping essential

• HCP in the facility where the patient has requested MAID can be a witness to patient’s written request as long as this individual: does not own the facility; and is not directly involved in the patient’s health care or personal care (consult your Risk/Quality of Care department for direction)

• Care coordination is essential, esp. w pharmacy

College of Nurses of Ontario (CNO)

• Outlines NP role in assessment, provision, documentation

• Supports RN and RPN role in providing nursing care, patient/family support, IV access, and assisting MD/NP in MAID

• RN/RPN may not administer medications for assisted dying or “encourage” MAID

• Nurses must not communicate conscientious objection to clients; transfer care to willing provider

Ontario College of Pharmacists (OCP)

• Emphasizes RPh and RPhT supportive scope

• If pharmacist is conscientious objector, must provide effective referral to a non-objecting alternate provider in a timely manner

• Must make referral for information to MD or NP

• Responsible to ensure eligibility criteria met/documented

• Emphasizes safe dispensing and disposal

Connect to the Values

• Ground yourself in your values

• What legacy does the patient (and family) want this conversation to have?

• What legacy do you want this conversation to have for you?

Connect to the Patient Story

• A requests for assisted dying is an invitation into story

• Requires curiosity, openness and narrative competence

– What might the patient really be saying?

– What is motivating the request?

– What is the feeling behind it all?

• The danger of one story

Connect to Resources

• Organizational policies and procedure

• Supports to address patient suffering:

• Supports for you and your team

Person-centered, Values-based, Evidence-informed

Understanding MAiD Through an Ontological Lens

• Ontology is the study of being

• The basic structure of all being is dialectical i.e., there is a self in dialogue with its environment

• The vocational self in the field of medicine is the practice of self in dialogue with a limit setting environment that includes the ethics and accountability of the profession and the needs/demands of persons receiving care

Understanding MAiD Through an Ontological Lens—Self

Self Values (incl. ethics

and morals) Beliefs

Experiences of life Family of origin

Culture(s)

Understanding MAiD Through an Ontological Lens—Self & Environment

Environment Other selves

w/values, experiences of life

and story Profession-

accountabilities and ethics

Self Values (incl. ethics

and morals) Beliefs

Experiences of life Family of origin

Culture(s)

Understanding MAiD Through an Ontological Lens-Changing Environ

Self Values (incl. ethics

and morals) Beliefs

Experiences of life Family of origin

Culture(s)

Environment Legal system-change

Profession-change i.e., we can aide

individuals seeking MAiD / organizational

change / change in prof. accountabilities

Understanding MAiD Through an Ontological Lens-After Adjustment

Changed Environment

Other selves & choice

Profession-adjusted accountabilities &

ethics

Adapted Self Culture(s)

Beliefs Values (incl. ethics

and morals) Experiences of life

Family of origin

How do I feel about this?

Questions: 1. How do I feel about MAiD? 2. How do I feel about being a part of the MAiD process? 3. What factors might influence how I feel about this? 4. What emotions am I aware of when I think about MAiD this way (it may be helpful to think of dominant emotions: fear/sadness/anger/happiness)? 5. How do I make sense of MAiD? As these questions are answered we may get a sense about… 6. How willing am I to fill medication orders; transport meds…?

Is this legal?

Historically, it has been a crime in Canada to assist

another person in ending his/her own life.

Bill C-14: An Act to amend the Criminal Code

and to make related amendments to other Acts

(medical assistance in dying) received royal

assent on June 17, 2016.

On June 17, 2016 the federal government enacted

amendments to the Criminal Code of Canada (the

“Criminal Code”) to include circumstances under which medical assistance in dying is permitted.

Is this legal?

Pharmacists and pharmacy technicians are now

exempted from criminal liability when

dispensing a prescription that is written by a

medical or nurse practitioner in providing

medical assistance in dying in accordance with

applicable federal legislation, provincial or

territorial legislation, standards, policies or

guidelines, is protected from criminal liability.

Eligibility

• All Ontarians are eligible, pursuant to a valid prescription and provided that the patient meets the specified eligibility criteria for MAID.

1. Be eligible for publically funded health services in Canada (ie have OHIP).

2. Be at least 18 years of age and capable to make decisions regarding health.

3. Have a grievous and irremediable medical condition.

4. Make a voluntary request for medical assistance in dying that is not a result of external pressure.

5. Provide informed consent after being informed of the means that are available to reliever their suffering, including palliative care.

Pharmaceutical Thought Process

• Indication

• Effectiveness

• Safety

• Cost

Indication

• Barbiturate and Derivatives – Secobarbital – Pentobarbital

• Opioids and Benzodiazepines – Morphine Sulfate – Hydromorphone – Midazolam

• Neuromuscular blockers – Rocuronium Bromide – Cisatracurium Besylate

Effectiveness

• Secobarbital and Pentobarbital not available in Canada.

• For oral meds, time to death post ingestion can range from minutes to hours, sometimes even longer.

• IV Medication, 15-20 minutes.

Cost

• ODB covers the full cost of MAiD kits and can be billed electronically for ODB patients.

– Intervention code ‘PS’: (Professional Care Services)

– Product Identification Number (PIN)

– Valid Pharmacist ID

– Professional Fee: The actual acquisition cost of the MAID kit

Cost

• Non-ODB eligible patients are billed manually (paper) as they need three intervention codes. – Patient Gender: ‘F’ = female; ‘M’ = male – Patient Date of Birth: Valid YYYYMMDD – Patient’s Ontario Health Card number – Intervention codes:

• PS: Professional Care Services • ML: Established eligibility coverage (i.e., 1 day of the Plan ‘S’ coverage) • MO: Valid Claim – value $500 to $999.99

– Carrier ID: ‘S’ – Product Identification Number (PIN): see table above for the list

of PINs – Valid Pharmacist ID – Professional Fee: The actual acquisition cost of the MAID kit

Am I authorized to dispense?

• All pharmacies/pharmacists in Ontario are authorized to dispense medications used for MAiD.

Do I have these drugs?

• All drugs that form part of the ODB funded MAiD kits can be ordered through your drug distributor.

• For the rare occasions when you are having trouble acquiring these medications, you can contact the BGH inpatient pharmacy.

MAiD Kits PIN PIN Description Contents Amount

Reimbursed

93877101 MAID intravenous (IV) Kit with Supplies

• Midazolam 1mg/mL • Lidocaine 2% (without epinephrine) • Magnesium Sulfate 500mg/mL • Propofol 10mg/mL • Cisatracurium Besylate 2mg/mL • Rocuronium Bromide 10mg/mL • Sodium Chloride (NaCl 0.9%) • Syringes and tubes

$325.00

93877102 MAID IV Kit (backup) with Supplies

Same as above $325.00

Acquisition Cost Midazolam $87.33/box $8.73/dose e.g. DIN 2382903 (Sandoz), McKesson 36364

Lidocaine $11.83/box $5.59/dose e.g. DIN 2421992 (Alveda), McKesson 593871

Magnesium $149.19/box ~$30/dose e.g. DIN 02139499 (Fresenius Kabi), McKesson 593871

Propofol $46/box $46/dose

MAiD Kits PIN PIN Description Contents Amount

Reimbursed

93877103 MAID IV Kit with Phenobarbital and Supplies

• Midazolam 1mg/mL • Lidocaine 2% (without epinephrine) • Magnesium Sulfate 500mg/mL • Propofol 10mg/mL • Phenobarbital 120mg/mL • Cisatracurium Besylate 2mg/mL • Rocuronium Bromide 10mg/mL • Sodium Chloride (NaCl 0.9%) • Syringes and tubes

$999.00

93877104 MAID IV Kit (backup) with Phenobarbital and Supplies

Same as above $999.00

Acquisition Cost Phenobarbital $142.73/box $356.83/dose e.g. DIN 2304090 (Sandoz), McKesson 363978

MAiD Kits PIN PIN Description Contents Amount

Reimbursed

93877105 MAID Self-Administration Kit (Hydromorphone/Morphine)

• Metoclopramide 10 mg • Ondansetron 8 mg • Propranolol 40 mg • Morphine Sulfate (liquid) • Morphine Sulfate 30 mg • Hydromorphone 1 mg/mL liquid • Hydromorphone 8 mg

$110.00

93877106 MAID Self-Administration Kit (Phenobarbital)

• Metoclopramide 10 mg • Ondansetron 8 mg • Phenobarbital 20 g • Chloral Hydrate 20 g • Morphine Sulfate 3 g • Haloperidol 5mg/mL

$250.00

Other drugs

• Health Canada’s Special Access Programme (SAP)

Acquisition Cost vs Reimbursed

• ODB: “You are at full liberty to charge the maximum reimbursed amount. No questions asked.”

• Me: “But what if the acquisition cost is less.”

• ODB: “We will pay the full amount if you bill it. If you want, you can bill less.”

• Me: “Any legal ramifications or future audit issues if there is a mismatch?”

• ODB: “No.”

Counselling

• Oral medication counselling must be offered to the patient or patient's agent and provided in person.

• The pharmacist can offer to provide counselling over the telephone.

• Instruct to take an antiemetic about one hour before ingesting oral meds to prevent nausea and vomiting.

• If vomiting occurs, instruct to contact ordering physician.

• If they decide not to end their life post ingestion, instruct them to contact 911.

• Unused medications should be brought back to the pharmacy for disposal.

Record keeping

• Same as any other prescription

Questions