Your Life. Your Choice: What is Medical Assistance in Dying?

Anna Toane

When you think about your death, especially if suffering is involved, what might you want it to look and feel like? Do you believe you should have personal autonomy over your end-of-life?

If the answer is yes then you probably also believe in medical assistance in dying (MAID). And if you live in Canada or a number of other countries around the world (parts of Australia, Belgium, Colombia, Luxembourg, The Netherlands, Switzerland, and several US States), there are current laws in place that “respect personal autonomy for those seeking access to MAID, while at the same time protecting vulnerable people and the equality rights of all Canadians.”

In a moving story, from a first-hand recount of a loved one’s experience with MAID, the author writes the “whole experience was calm and peaceful. This is what a medically assisted death … should look like. It includes engagement by the patient, compassionate hospice staff, supportive friends and family in attendance and a caring medical practitioner administering the procedure.” By supporting MAID it also supports our right to choose our own good death.

In June 2016, the Parliament of Canada passed federal legislation that allows eligible Canadian adults to request medical assistance in dying. The bill strikes:

An appropriate balance between the autonomy of those individuals seeking access to medical assistance in dying and the interests of vulnerable persons and of society, through amendments to the Criminal Code to allow physicians and nurse practitioners to provide assistance in dying to eligible competent adults in accordance with specified safeguards.

Death and dying can be difficult subjects to think and talk about and here at Eirene we’re committed to providing simple, compassionate, and transparent services to Canadians. Our mission is to unpack difficult conversations around end-of-life planning and help families navigate the complexities of death care. Our vision is to ensure that a better death becomes integral to a good life. In line with this vision of a better death is access to MAID.

Why MAID Is An Important (and complex) Part of the Conversation

As Sandra Martin expresses in her article MAID is an important consideration, as without it “[p]atients must either forgo the death they want, and suffer until they finally expire, or spend their last days and hours being shunted from place to place” (as some hospice care facilities won’t provide MAID onsite and are transferred to a different facility, often resulting in more pain and discomfort).

She goes on to say “[r]econciling the rights of doctors to practise medicine with the rights of patients to receive treatment, wherever they live, is the next imperative in the ongoing struggle to make our final human right—choice in the manner and timing of our deaths—equitable for all Canadians.”

According to The National Center for Biotechnology Information there are both positives and negatives to the choice of MAID. Among the pros, “patient autonomy, relief of pain and suffering, and safe medical practice.” And among the cons, “suicide contagion” and a “slippery slope,” they argue “once doctors are involved in the business of hastening patients’ deaths; they have already slid down the slippery slope.” They deduce that MAID “remains a controversial subject relevant to the care of patients,” that “[s]trong arguments remain both in favor and in opposition to the practice, and physicians have an ethical responsibility to remain informed on this timely issue.”

Despite it being a complex consideration, dying with dignity is understood as a basic human right, and should therefore be part of all end-of-life conversations.

A SnapShot: MAID In Canada

According to the Government of Canada, the number of medically assisted deaths is steadily increasing:

• In 2019, there were 5,631 cases of MAID reported in Canada, accounting for 2.0% of all deaths in Canada
• The number of cases of MAID in 2019 represents an increase of 26.1% over 2018 numbers, with all provinces experiencing a steady year over year growth in the number of cases of MAID since its introduction into law in 2016
• When all data sources are considered the total number of medically assisted deaths reported in Canada since the enactment of federal legislation is 13,946.

Types of MAID Permitted in Canada

There are two types of MAID allowed:

1. A physician or nurse practitioner can directly administer a substance that causes the death of the person who has requested it
2. A physician or nurse practitioner can give or prescribe to a patient a substance that they can self-administer to cause their own death

Eligibility

It’s important to note that the laws differ by province and territory in Canada. For more information on navigating a request, you can consult Dying With Dignity’s website here.

To receive medical assistance in dying in Ontario, a patient must:

• Be eligible for publicly funded health care services in Canada
• Be 18 years of age or older
• Be capable of making health care decisions
• Have a grievous and irremediable medical condition, which means the patient:
• Has a serious and incurable illness, disease or disability
• Is in an advanced state of irreversible decline in capability
• Is enduring physical or psychological suffering, caused by the medical condition or the state of decline, that is intolerable to the person
• Natural death has become reasonably foreseeable

Your doctor or nurse practitioner will determine if you meet all the eligibility requirements and a second doctor or nurse practitioner must also complete another assessment (second opinion) to confirm that you meet all the eligibility criteria.

Important To Know

In order to move ahead with this choice you will need to speak with your doctor or nurse practitioner. While some doctors or nurse practitioners may not want to provide MAID, they must however refer you to another doctor or nurse practitioner who is willing to move forward with your request.

There are a few important considerations that will help you better understand your choice:

• You must personally consent to medical assistance in dying and unlike other advanced care plans, another person, such as a substitute decision maker, cannot consent to medical assistance in dying on your behalf, or make the request for you
• You cannot give consent in advance and you must be able to provide consent until the moment you receive medical assistance in dying
• You can withdraw your request at any time
• Even if you make the request, you can still receive all the other types of health care you need from your doctor or nurse practitioner

The Process

You can learn more by visiting Health Canada’s website here.

*You may withdraw your request at any time.

1. Speaking to your doctor/healthcare team. This also includes being informed of all care options available to help relieve suffering
2. Formal request in writing
3. Your doctor or nurse practitioner can provide you with a Patient Request form, available here, to complete
4. Determine eligibility and undergo medical assessment
5. Second opinion
6. Waiting period of 10 days (in some cases, the doctors or nurse practitioners may approve a shorter waiting period): time to think about your decision and the opportunity to withdraw your request at any time
7. An exception may be made to the 10 clear day reflection period if both your first and second medical or nurse practitioner agree that:
8. your death is fast approaching OR
9. you might soon lose your capacity to provide informed consent
10. How you receive the drugs is your choice: your doctor or nurse practitioner will either give you the drugs, or will write a prescription for you to fill on your own. This means you take the drugs yourself in a setting of your choice
11. Right before giving you the drugs or the prescription, your doctor or nurse practitioner will:
12. Give you another opportunity to withdraw your request
13. Confirm that you are still mentally capable of making this choice
14. Get your final consent to proceed

An Alternative to MAID

Because access to MAID is restricted by law some patients may “turn to voluntary stopping eating and drinking (VSED) or voluntary stopping personal care (VSPeC) as an alternative to MAID or as a path to MAID.”

Personal care is understood as:

• Artificial nutrition and hydration
• Being spoon fed
• Regular changing of positions (for example, for someone with paralysis to prevent bedsores)

So, is it legal?
According to the End-Of-Life Law & Policy Health Law Institute at the University of Dalhousie

VSED is a legal alternative to MAID for most people in Canada.Competent patients can legally cause their own death through VSED because they can legally refuse artificial and oral nutrition and hydration. The Canadian common law clearly holds that competent adult patients can refuse medical treatment even when that refusal has the direct consequence of death.

Once again though, it’s important to note there are some nuances by province and territory. More of which can be understood here.

What Will Happen After I Die?

Under current law, all medically assisted deaths in Ontario must be reported by the doctor or nurse practitioner to the Office of the Chief Coroner. While the Coroner must be notified of all medically assisted deaths, an investigation is not required unless the Coroner deems one to be necessary.

Patients who choose to take the prescribed drugs on their own are encouraged to share their plans and the contact information of their doctor or nurse practitioner with family or friends, or in writing somewhere easily located.

This will help ensure authorities are aware the death was planned. Patients should make sure that they or their family can provide all the information and documentation that the doctor, nurse practitioner or coroner may require.

A Canadian Resource: Dying With Dignity

Dying With Dignity (DWD), a human-rights charity “committed to improving quality of dying, protecting end-of-life rights, and helping Canadians avoid unwanted suffering.” They aim to:

• Educate people about end-of-life options
• Defend human rights by advocating for assisted dying rules
• Support individuals at the end of their lives, and
• Provides support to healthcare practitioners who assess for and provide MAID

DWD provides four programs: access, eligibility, support, and education.

The Debate Has Only Just Begun

“On February 24, 2020, the federal government tabled Bill C-7in Parliament to amend the federal legislation on MAID. Proposed changes to the legislation included:

• Removing the eligibility requirement for a reasonably foreseeable natural death;
• Waiving the requirement for final consent in those circumstances where persons approved for MAID risk losing capacity to consent before their scheduled date for MAID, and they have an advance consent agreement with their practitioner;
• Adding safeguards to ensure that adequate time and expertise are devoted to the eligibility assessment of persons whose natural death is not reasonably foreseeable; and,
• Enhancing the reporting requirements for the national monitoring regime to allow for data collection on assessments for MAID where a request has not been put in writing and to collect information on preliminary assessments that are conducted by other health care professionals.

So it’s clear the conversation is far from over and there is much to consider, and from many different angles and access to MAID continues to be a challenge. As Sandra Martin eloquently writes in her 2018 opinion piece:

As a journalist, I believe in the power of narrative. Personal stories can alter perceptions, as I have learned in writing about the hopes and fears of patients, the anguish of survivors scarred by the trauma of watching loved ones suffer and the courage of doctors who risk censure and opprobrium to care for their patients. But personal stories aren't enough. We need compliance, oversight and regulation.

Nevertheless, an idea that was once impossible to imagine is becoming normalized. An estimated 2,500 people in Canada have died with medical assistance in the past three years. There is no turning back. We are a country that recognizes that medical assistance in death is a human right, however limited the access and however myriad the hurdles. For every step forward, however, new roadblocks pop up, forcing patients and their families to play a desperate end-of-life version of a demonic video game.

Despite the changing culture around death and dying, and the still new legalization of MAID, access to MAID is still challenging and ultimately adds an additional burden on the patient and their loved ones. As Martin movingly writes, “[h]elping somebody die is a supremely intimate and definitive medical intervention. That’s why we need to pull the shroud off death, the mysterious concept, and talk openly about end-of-life wishes.”

We’re here to support you and have made it our mission to unpack difficult conversations around end-of-life planning and navigating the complexities of death care.

To learn more and access additional resources visit www.eirene.ca.