Medical Assistance in Dying Community of Practice September 15, 2017

MAID Community of Practice (CoP) Webinars Discussion forum to support : Awareness of resources to enable HCP to meet their professional obligations when a patient makes an inquiry or request for MAID Sharing of lessons learned from local MAID cases Identify regional and sub-region needs to support MAID requests Identification of knowledge gaps requiring systemic education/ support Brainstorm collaborative solutions to current challenges being experienced by Health Service Providers supporting requests for MAID

This teleconference is open to all health service providers who are: Currently dealing with a request for MAID, OR Have supported a request for MAID in the past, OR Are considering supported a MAID request in the future and / or are interested in engaging in a collaborative discussion with other health service providers to learn from local experiences in supporting access to MAID in WW.

Updates Provincial MAID Care Coordination Service Transitioning to the regions/LHINs WWLHIN will serve as the WW Regional MAID Care Coordination service Completed a call for clinicians interested in supporting MAID Education, mentoring Additional call for interested partners to join Regional MAID Clinical Working Group to support development of clinical tools/resources e.g. intake/referral form, MAID Supply List, IV access support in LTC Contact Emmi Perkins (emmi.perkins@lhins.on.ca) if you are interested in contributing to this working group

WW MAID Regional Framework DRAFT For Discussion (Sept 14, 2017)

Medical Assistance in Dying - CMA Joule Program for Physicians & NPs In-person and On-line course options In-person – 8 hour workshop On-line 4-week course Topics: Legal and Regulatory Concerns Consent and capacity: clinical context and application to assisted dying Technical aspects of medical assistance in dying Case analysis and discussion Medical Assistance in Dying - CMA Joule Program An overview of the advanced course on medical assistance in dying Face-to-face in-house option: Features of this one-day course include the following (please see Appendix C for the agenda):  One-day face-to-face course  Multi-disciplinary faculty who are experts in medical assistance in dying in Canada  A focus on interactivity and case-based learning  In-person experience creates a greater opportunity for participants to build their own community of practice through face-to-face discussions  An opportunity to join a post-course online community of practice with colleagues from across the country  Class size is capped at 40 participants to ensure optimum learning outcomes Online in-house option: Features of this course include the following (please see Appendix D for the agenda):  Four week facilitated course comprised of one module per week that will require three to four hours of study each week  Multi-disciplinary faculty who are experts in medical assistance in dying in Canada.  Participants can interact with each other and with course faculty through a discussion forum and weekly webinars  Class size is capped at 35 participants to ensure optimum learning outcomes  Technical support for online learning provided Learning Objectives: At the end of this course, you will be able to:  Integrate and fulfill ethical principles and legal and regulatory requirements in the care of patients requesting medical assistance in dying  Evaluate competency especially with vulnerable populations  Engage in a complex conversation with patients and their families at end of life  Provide the technical aspects of assisted dying in a compassionate manner  Self-monitor and reflect to assess impact in personal and professional life  Access support around self-care

Provincial Landscape Total number of cases completed in Ontario as of: July 31, 2017 = 617 616 physician-administered cases, 1 patient administered cases 407 Cancer-Related, 44 ALS, 47 Other Neurological, 73 CV/Resp., 46 Other 338 in hospital, 233 in private homes, 33 in LTC, 23 in retirement homes Female: 295, Male: 322 Average Age: 73 (range 27 -101) Number of Unique MAID Providers: Clinicians: 196 (Physicians 192 , NPs 4), Hospitals: 74 22 cases in WW (13 Wellington, 9 Waterloo) Note: Does not include the 13 court authorized cases from February 6, 2016 to June 6, 2016, for which data is not available *Home includes: residence, long term care centres and seniors/assisted living

MAID in WWLHIN

Case #1 WW Feedback to Provincial Coroner "It took over 1 hour for the Coroner to respond. The physician, nurses and funeral home had to stay in the home waiting for the response. Family was okay with the wait, but it is not ideal. Procedure was at 0700h and therefore impacted the response of the coroner's office. Consider a pre-call to Coroner's office prior to the procedure when outside of office hours to perhaps prepare the office for the call." Given these are known/planned death, and our efforts to optimize the experience of the providers and family members, how would your staff prefer to be notified (or not) of cases that may be outside of normal office hours to minimize the delay in responding (if possible).

Case #1 (cont’d) Response from Provincial Coroner The team members all agree that callers should expect a response from the team within 30 minutes--so please provide guidance that if the clinician does not hear back within 30 minutes they should re-contact our Provincial Dispatch staff--1-855-299-4100. Having said that there may be occasional times when the team member will be unable to meet the time frame (travelling in a car, managing another case). Other procedure changes/opportunities include; The team now has a dedicated fax line/email account to enhance the transfer of documents; availability for secure email transfer of documents; and if it would be of assistance the clinician can scan the majority of the records into a pdf in advance(but not send to us) to allow easier and timelier transfer of records after the death.

Case #1 (cont’d) Response from Provincial Coroner As you are likely aware, the team is not at full complement given the rapid development and the initial need for contract positions. We are proceeding with posting for permanent positions which should allow us to be fully staffed over the next few months. All of this as background to answer the suggestion--Given the expectation that the team responds within 30 minutes unless there are extenuating circumstances, I do not believe that a pre- procedural call would make a significant difference. Given the sharing of work and transfer of call duties pre-procedural calls could in fact cause more difficulty.

Case #2 Family has decided that since funeral home is not an option and family not comfortable hosting, they have agreed to Stratford General being the site to receive MAID Tuesday October 3.

Case #3 Patient transferred from Hospice Wellington to GGH for MAID procedure

Other Cases?

Recent Cases/Challenges/Opportunities Encourage early involvement of HPC Team especially regarding date of procedure

Completion of Death Certificate Upon receipt of a report regarding a medically assisted death, the Coroner will determine whether the death ought to be investigated. If the Coroner determines that an investigation is not required, the attending physician or nurse practitioner who provided medical assistance in dying must complete the medical certificate of death. However, if the Coroner is of the opinion that the death ought to be investigated, the medical certificate of death must be completed by the Coroner. As directed by the province, when completing the death certificate for a medically assisted death, the illness, disease, or disability leading to the request for medical assistance in dying must be recorded as the underlying cause of death. Physicians are to make no reference to medical assistance in dying, or the drugs administered to achieve medical assistance in dying, on the death certificate. http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-in-Dying

10-day Reflection Period A period of at least 10 clear days22 must pass between the day on which the request for medical assistance in dying is signed by or on behalf of the patient, and the day on which medical assistance in dying is provided. In accordance with federal legislation, this timeframe may be shortened if both the physician(s) and/or nurse practitioner(s) agree that death or loss of capacity to provide consent is imminent. Physicians must document the start and end-date of the 10-day reflection period in the medical record, and their rationale for shortening the 10-day reflection period if applicable. http://www.cpso.on.ca/Policies-Publications/Policy/Medical-Assistance-in-Dying

Was this discussion valuable Was this discussion valuable? What else is required to support you with respect to MAID?