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Canadian doctors encouraged to bring up medically assisted death before their patients do

A guidance document produced by Canada’s providers of medically assisted death states that doctors have a professional obligation to bring up MAID

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In most jurisdictions in the world with legalized euthanasia, doctors are explicitly prohibited, or strongly discouraged from raising assisted dying with a patient.

The request must come from the person.

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But a guidance document produced by Canada’s providers of medically assisted death states that doctors have a professional obligation to bring up MAID as an option, when it’s “medically relevant” and the person is likely eligible, as part of the informed consent process.

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There is no legal restriction on who can raise the subject of MAID with someone with a grievous and irremediable illness, disease or disability, provided the intent is not to induce, persuade or convince the person to request an assisted death, says the Canadian Association of MAID Assessors and Providers.

But some ethicists argue that introducing death as a “treatment option,” without the person suggesting it first, is seriously problematic, especially within the expanding realm of MAID, and that people could be unduly influenced to choose to have their life intentionally ended, given the power dynamics of the doctor-patient relationship.

“Some people, no matter how well-handled your conversation, may infer that it’s essentially a suggestion,” said University of Toronto bioethicist Kerry Bowman.

Some people, no matter how well-handled your conversation, may infer that it’s essentially a suggestion

“They would also definitely infer that they have the strong potential to meet eligibility criteria, or you wouldn’t be offering it.”

The CAMAP document was created and published in early 2019, when MAID was still restricted to those whose natural death was reasonably foreseeable. However, it remains a guide for doctors and nurse practitioners navigating MAID as eligibility criteria expand. The subject of “bringing up MAID” is the topic of one of the components of new MAID curriculum under development, and it was part of a free, professional development webinar for health-care providers this week.

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“We’ve been working on this for quite some time,” said CAMAP’s vice president, Dr. Konia Trouton.

Canada’s assisted dying law states that no health-care professional commits an offence “if they provide information to a person on the lawful provision of medical assistance in dying.” Canada’s MAID providers and assessors said that there is also no provision in the law that prohibits clinicians from initiating the discussion and raising the possibility of MAID.

While it is absolutely illegal to counsel someone to die by suicide, to “counsel,” from a doctor-patient perspective, means to “inform and discuss,” the group’s guidance reads.

“The clinical perspective of the meaning of the word ‘counsel’ has no bearing on the legal meaning.”

The timing should be at the discretion of the doctor, the group recommends. In almost all cases, it would be inappropriate immediately upon delivery of a grim and irremediable diagnosis, they noted. “However, once options for all treatment options including cessation of treatment are presented to the patient, it would be appropriate to disclose the availability of MAID.”

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“We have to make sure that people are aware of their options,” Trouton said. “Awareness is not the same as coercing them or pushing them in that direction.”

Awareness is not the same as coercing them or pushing them in that direction

MAID would never be raised solely, in and of itself, she said, but within the context of discussing “goals of care” and “values clarifications.”

“There shouldn’t be any ethical tension in bringing up with a patient that has a serious illness, disease, or disability, ‘What are your goals? What are your hopes? What are the things you want done and do not want done?

“’Do you want to move to a nursing home? Do you want to be resuscitated? Do you want CPR? Do you want to be in the intensive care unit?’ And within that, ‘Is assistance to die something that is ethically abhorrent to you or acceptable to you? Is that something you want to explore more, or not?’”

Not providing information about MAID in a “timely manner” to someone who might be eligible for MAID can create harm, Trouton’s group said.

People may suffer intolerably for longer, lose the capacity to consent “or have an end-of-life experience which may be unacceptable to them.” One palliative care doctor, writing in the Canadian Medical Association Journal in 2019, describes the case of Leo, a young man with terminal, incurable cancer and escalating, excruciating nerve pain who died by suicide by overdosing on his pain medication. “His elderly mother found him. Panicked. Called 911,” Dr. Susan MacDonald wrote. He was taken to an emergency department, “his body invaded by tubes and drugs in a futile attempt to reverse what he had set in motion. He died surrounded by strangers. Naked. On a gurney.”

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He had never brought up the subject of MAID. Nor had his conflicted doctor.

Not raising MAID could mean to deny people’s rights, Bowman said, “because there are people out there that think, ‘If I was eligible, (the doctor) would have brought it up.’” Those living in isolated areas, or people new to Canada, may not know assisted death is legal in this country, he said.

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The case of a Veterans Affairs caseworker who reportedly suggested to a combat veteran with PTSD that MAID was a better option than “blowing your brains out against the wall” drew outrage.

“We don’t know how that conversation played out,” Bowman said. “But I suspect what is happening across the country is that some people are bringing it up regularly and some people aren’t.”

Many people in health care are risk avoidant, he said. “Knowing that someone could interpret their conversation as encouraging suicidality is enough to stop a lot of people from even bringing it up. Because that is clearly illegal.”

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“In a perfect world, a doctor that’s familiar with a patient’s wishes and values will be able to make some better decisions about when and how to bring it up,” Bowman said. But given Canada’s hugely stressed health-care systems, “there are lots of doctors that are not familiar with the patient’s wishes and values at all.”

The expansion of MAID to those not at imminent risk of dying adds another layer of complexity and debate, he said. “I also see it as very problematic when we bring (MAID) up to people who can’t pay the rent, or people who are living with disability who don’t have adequate access to the things that they need,” Bowman said.

Within the mental illness context, “imagine what this means,” said Trudo Lemmens, a professor of health law and policy at the University of Toronto.

“You have a person who is severely depressed where the nature of the illness is often accompanied by a desire to die. The person takes a step to go and see a mental health counsellor to get help, and is being told, as part of the informed consent procedure, we can have treatment a, b, c or MAID.”

It’s being sold as a normal medical practice

In Canada, in contrast to just about all other jurisdictions, MAID is no longer seen as an exceptional procedure, Lemmens said.

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“The fact that this has been presented as, ‘This has to be on the table because it’s part of informed consent,’ reflects, overall, an attitude that has developed in the Canadian context,” he said. “It’s being sold as a normal medical practice.”

That, in his view, was not what the Supreme Court of Canada required when it struck down the criminal prohibition on assisted death in 2014 in Carter v. Canada.

It also reflects an overemphasis in Canada on “access,” Lemmens said, “and the alleged harm of not immediately having access to MAID, rather than on the risk of premature death.”

Trouton said CAMAP’s guidance document and the concept of bringing up MAID is for people with a grievous and irremediable condition. “While those people don’t need to have a reasonably foreseeable death, that is often the case.”

In New Zealand and Victoria, Australia, two jurisdictions where assisted dying for the terminally ill was recently legalized, doctors are explicitly prohibited from bringing it up. While it’s not explicitly prohibited in Belgium and the Netherlands, “it is generally not considered appropriate,” Leemens said, especially outside the end-of-life context.

“The emphasis is on how the request must come from the patient.”

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