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Toronto Notes 2019 Ethical and Legal Issues in Canadian Medicine Ethical, Legal, and Organizational Medicine ELOM15
• deathshouldbetheconsequenceofthemorallyjustifiedwithdrawaloflife-sustainingtreatments only in cases where there is a fatal underlying condition, and it is the condition (not the withdrawal of treatment) that causes death
• anargumentpresentedintheCartercase(seebelow)suggestedpermittingMAiDwilldetractsupport for palliative care, since with proper palliative care, the number of requests for MAiD would decrease. This argument was rejected in Carter v Canada, as making people suffer to potentially improve care for others is not acceptable
Legal Aspect
• intheCarterv.CanadadecisionofFebruary2015,thecriminalprohibitiononassistanceinsuicide was ruled unconstitutional to the extent that they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.
• BillC-14(June17,2016)legalizedMAiDbyamendingtheCriminalCodetocreateexemptions permitting medical practitioners to provide MAiD, specified the eligibility criteria, safeguards, and required documentation and authorization from the Minister of Health, as well as new offences for failure to comply with the new regulations. http://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/ royal-assent
■ as the Bill C-14 criteria are narrower than the Carter decision, there are ongoing constitutional challenges to the MAiD framework as it currently stands.
Bill C-14 Criteria for MAiD
• patientiseligibleforpublicly-fundedhealthservicesinCanada
• atleast18yrofage,andhascapacityforclearandfreelygivenconsent
• grievousandirremediablemedicalcondition:inanadvancedstateofirreversibledeclineincapability • sufferingintolerabletothepatient,notrelievedunderconditionstheyconsideracceptable
• naturaldeathisreasonablyforeseeable
MAiD Process
1. eligibility criteria satisfied
2. patient signs and dates a written request for MAiD
3. two independent witness sign the written request. Witnesses must be 18 years of age, understand the
nature of MAiD, and must not a) benefit (financially or otherwise) from the death, b) be an owner or operator of the healthcare facility where the patient is receiving care, c) be directly involved in the provision of health or personal care of the patient
4. HCP must inform the patient that they can withdraw their consent at any time
5. two independent assessors (MD or NP) must provide written confirmation that eligibility criteria are
met
6. 10 clear days must elapse between the request and the day on which MAiD is provided, unless both
healthcare providers agree that a shorter period is appropriate due to the patient’s imminent death or
loss of capacity
7. immediately before providing MAiD, the HCP must give the individual an opportunity to withdraw
the request and ensure that the patient gives express consent to receive MAiD
◆ contravention of this process is an offence punishable by up to five years in prison
Acceptable Use of Palliative and End-of-Life Care
• theuseofpalliativesedationwithopioidsinend-of-lifecare,knowingthatdeathmayoccurasan unintended consequence (principle of double effect) is distinguished from euthanasia and assisted suicide where death is the primary intent
• theappropriatewithdrawaloflife-supportisdistinguishedfromeuthanasiaandassistedsuicideasit is seen as allowing the underlying disease to take its ‘natural course’, but this distinction may be more theoretical than real
• consentforwithdrawaloflife-supportmustbesoughtfromSDMs,asruledinCuthbertsonv.Rasouliin 2013, as palliative care would be instituted and consent for that would require SDM consent
• refusalsofcarebythepatientthatmayleadtodeathaswellasrequestsforahasteneddeath,oughttobe carefully explored by the physician to rule out any ‘reversible factors’ (e.g. poor palliation, depression, poverty, ill-education, isolation) that may be hindering authentic choice
• GovernmentofCanada–ServicesandInformationforEnd-of-LifeCare:https://www.canada.ca/en/ health-canada/topics/end-life-care.html
■ options and decision making at end of life: palliative care, do not resuscitate orders, refusal or withdrawal of treatment, refusal of food and drink, palliative sedation, MAiD
■ decisions at end of life: Informed and capacity for consent, substitute decision maker, advanced care planning (written plan, will, or medical directive) often established through a family meeting
Physician Responsibilities Regarding Death
• physiciansarerequiredbylawtocompleteamedicalcertificateofdeathunlessthecoronerneeds notification; failure to report death is a criminal offence
• Coroner’sAct,1990(specifictoOntario,similarinotherprovinces)requiresphysicianstonotifya coroner or police officer if death occurs:
■ due to violence, negligence, misconduct, misadventure, or malpractice ■ during pregnancy or is attributable to pregnancy
Mental Health Outcomes of Family Members of Patients Who Request Physician Aid in Dying
J Pain Symptom Manage 2009;38(6):807-815 Purpose: To describe how patients’ end-of-life choices affected family caregivers of Oregonians who requested aid in dying and to assess degree of grief, use of mental health services and depression amongst family caregivers.
Methods: Family members of Oregonian patients who had explicitly requested aid in dying (including those whose loved ones received a lethal prescription and those whose loved ones died by lethal ingestion) were surveyed. For comparison purposes, family members of patients who died of cancer or amyotrophic lateral sclerosis also were surveyed.
Results: 95 family members were surveyed, including 59 of those whose loved ones received a lethal prescription and 36 whose loved ones died by lethal ingestion. Among those whose family member requested aid in dying, whether or not
the patient accessed a lethal prescription had no influence on subsequent depression, grief, or mental health services use; however, family members of patients who received a lethal prescription were more likely to believe that their loved one’s choices were honored and less likely to have regrets about how the loved one died. Comparing family members of those who requested aid in dying to those who did not revealed no differences in primary mental health outcomes of depression, grief, or mental health services use. Family members of patients who requested aid in dying felt more prepared and accepting of the death than comparison family members.
Conclusion: Pursuit of aid in dying does not have negative effects on surviving family members and may be associated with greater preparation and acceptance of death.
Notify Coroner if Death Occurs due to:
• Violence, negligence, misconduct • Pregnancy
• Sudden or unexpected causes
• Disease not treated
• Cause other than disease • Suspicious circumstances • MAID