End-of-life care in Canada:A principles-based approach to assisted dying

Dr. Jeff BlackmerVice-President, Medical Professionalism

CMA activities on end-of-life care

What’s new since we last met in Ottawa

Activities on end-of-life care

• The CMA revised its policy on assisted dying based on feedback from 2014 General Council

• We developed and released a comprehensive report on palliative care designed to be a national call to action to improve access to quality palliative care

• We undertook further extensive consultation with our members and with key stakeholders on a principles-based approach to assisted dying

CMA intervention in Carter v. Canada

October 15, 2014

CMA appeared as an intervener - a friend of the court –in Carter v. Canada to present key considerations:

→ CMA supports members on both sides of the issue

→ The profession, like the public, is divided

→ There are important practical considerations to be considered

→ End of life discussions need to be supported and become a part of routine medical practice

→ Canada needs a national palliative care and end of life strategy

February 6 2015:

Held:  The appeal should be allowed.

Section 241 b and s. 14 of the Criminal Code unjustifiably infringe s. 7 of the Canadian Charter of Rights and Freedoms.

CMA principles-based approach to assisted dying

Principles-based approach to assisted dying

Ten principles:

1. Respect for autonomy 6. Dignity of life

2. Equity 7. Protection of patients

3. Respect for physician values 8. Accountability

4. Consent and capacity 9. Solidarity

5. Clarity 10. Mutual respect

Principles-based approach to assisted dying

Recommendations:

1. Patient qualifications for access to medical aid in dying

2. Process map for decision-making in medical aid in dying

3. Role of the physician

4. Responsibilities of the consulting physician

5. Moral opposition to medical aid in dying

Consultation process

June – July 2015 Online survey (1407 responses) Online dialogue (595 participants) Stakeholder consultation Individual member consultation

CMA member consultation

Key online survey results

Following the Supreme Court of Canada decision regarding medical aid in dying, would you consider providing medical

aid in dying if it was requested by a patient?

If Yes: Would you provide medical aid in dying to someone whose suffering was purely psychological?

If Yes: Would you provide medical aid in dying to someone not suffering from a terminal illness?

If a physician refuses to provide medical aid in dying, what should they be required to do?

What do you believe the role of the CMA should be in relation to medical aid in dying?

%

Would you consider providing medical aid in dying if it was requested by a patient? 2014 v. 2015

20144 20154

CFPC ePanel: Do you agree with the recent Supreme Court of Canada decision that struck down sections of the Criminal Code

that prohibit physicians from helping patients die?

CFPC ePanel: Would you help a competent, consenting dying patient end her/his life if requested?

CMA stakeholder and member consultation

Key strategic questions and responses

1. What should be the processes followed after the patient requests medical aid in dying?

2. The Supreme Court of Canada has laid out broad terms which patients will qualify for assistance in dying. Should there be other clinical specifications or requirements?

3. Some physicians will choose not to participate in assisted dying for reasons of conscience. What specific mechanisms can physicians employ to ensure this access?

Key strategic questions

• There was wide agreement that the first response should be to assess patient needs and provide alternative treatment options

• There was wide agreement there should be procedural safeguards to assess and respond to requests and that it requires expertise and training

• There was disagreement on the appropriate timeline with some suggesting it should be shorter and others suggesting it should be longer

Process to respond to request

Questions to consider:

1. Does the proposed timeline require revision?

2. Should the process include a palliative care or a psychiatric consultation as a requirement? And/or should the consulting physician be a palliative care physician?

3. Should we further clarify the roles and next steps if there is a disagreement in the assessment of the patient?

Process to respond to request

Clinical specifications and requirements

• There was wide agreement that the eligibility criteria defined in Carter are problematic, i.e., what does “grievous and irremediable” mean clinically?

• There was disagreement on the appropriate scope of eligibility with some suggesting narrow criteria and others suggesting broad criteria should be adopted

• There were some suggestions that the waiting (“cooling off”) period should be proportionate to the patient’s expected prognosis, i.e., a standard waiting period is not appropriate for all requests

Questions to consider:

1. What would be an appropriate scope of eligibility, i.e., narrower vs broader criteria?

2. Should the prognosis, e.g., a terminal illness vs chronic pain, be taken into account in determining the process?

Clinical specifications and requirements

1. The vast majority expressed the view that physician conscience rights must be integrally protected

→ There was disagreement on what that means with conceptions of conscience as opposition, procedural non-participation, non-interference, and participation

Conscientious objection

2. There was agreement that the exercise of conscientious objection must be protected in a way that balances patients’ ability to access assisted dying

→Options were discussed to support differences in conscience, in the form of the duty to refer, duty to provide information, no duty

Conscientious objection

Options to consider:

1. Duty to refer directly to a non-objecting physician

2. Duty to refer to an independent third party

3. Duty to provide complete information on all options and advise on how to access directly a separate central information, counseling, and referral service

4. Patient self-referral to a separate central information, counseling, and referral service

Conscientious objection

1. Duty to refer directly to a non-objecting physician

PROS→ It is the most direct way to facilitate patient access

CONS→ It does not respect conceptions of conscience for which a duty to refer is

morally unacceptable

→ Referral implies forced participation procedurally that may be connected to, and would be complicit in, a morally unacceptable act

Conscientious objection

2. Duty to refer to an independent third party

PROS→ It facilitates access to a designated third party who would act as an

information, counseling and referral service → It is consistent with Quebec legislation

CONS→ It does not respect conceptions of conscience for which a duty to refer is

morally unacceptable

→ Referral implies forced participation procedurally that may be connected to, and would be complicit in, a morally unacceptable act

Conscientious objection

3. Duty to provide complete information on all options and advise on how to access a separate central information, counseling, and referral service

PROS→It provides the patient with complete information and facilitates access to a service

→It is the most widely morally acceptable option that takes account of, and respects, differences in conscience, while facilitating access to a service

CONS→It presupposes that there will be a central information service

Conscientious objection

4. Patient self-referral to a separate central information, counseling, and referral service

PROS→It does not compel physicians opposed to assisted dying to participate in any way

CONS→It presupposes that there will be a central information service

→It does not facilitate patient access in any way

Conscientious objection

Next Steps

• GC Delegate discussion and feedback

• Use of framework to help shape legislation and regulations at the federal and provincial levels

End-of-life care in Canada:A principles-based approach to assisted dying

Dr. Jeff BlackmerVice-President, Medical Professionalism