Medical Assistance in Dying Community of Practice January 12, 2018

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 supporting 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 by the end of March 2018 Second round of CMA MAID Joule Courses being offered WWMAID Clinical Working Group EDITH protocol adapted to include MAID MAID Checklist drafted MAID Intake Form being developed MAID Peer Group meets the 4th Monday of each month from 7:00-8:30pm @ WWLHIN Guelph Office (450 Speedvale Ave W, Guelph) Seeking an organization to support this group

Updates - Monitoring of Medical Assistance in Dying – Federal Reporting Regulations The federal MAID legislation authorizes the federal Minister of Health to enact regulations to establish a pan-Canadian monitoring regime for MAID.   The federal regulations will address the information to be provided, how and when it must be provided, to whom, and its use and disposal. The objectives of the proposed monitoring regulations are to: Support public accountability and transparency in relation to MAID; Support the protection of vulnerable individuals by monitoring the application of the eligibility criteria and safeguards required by the legislation; Identify and monitor trends in requests for, and the provision of, MAID; Help determine whether the legislation is meeting its objectives; and Make data available to qualified researchers for the purpose of enabling independent analysis and research.

Updates - Monitoring of Medical Assistance in Dying – Federal Reporting Regulations The draft federal reporting regulations were published by Health Canada in Canada Gazette on December 16.  Canadians, including health care sector stakeholders, have 60 days to provide feedback to the federal government. The deadline is midnight on Tuesday February 13, 2018. In an effort to reduce the reporting burden on MAID clinicians, MOHLTC is working with Health Canada to ensure alignment between the federal MAID monitoring regime and Ontario’s MAID oversight regime http://gazette.gc.ca/rp-pr/p1/2017/2017-12-16/html/reg6-eng.html

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

Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data County MAiD Cases Algoma County 5 Brant County 8 Bruce County 6 Chatham - Kent Division < 5 Cochrane District 7 Dufferin County Durham Regional Municipality 22 Elgin County Essex County 12 Frontenac County 32 Greater Sudbury Division Grey County 11 Haldimand-Norfolk Regional Municipality 9 Haliburton County Halton Regional Municipality 34 Hamilton Division 43 Hastings County 14 Huron County Kawartha Lakes Division Kenora District Lambton County Lanark County Leeds & Grenville United Counties 17 County MAiD Cases Lennox & Addington County < 5 Middlesex County 66 Muskoka District Municipality 7 Niagara Regional Municipality 21 Nipissing District Northumberland County 9 Ottawa Division 94 Oxford County Parry Sound District Peel Regional Municipality 73 Perth County Peterborough County 26 Prescott & Russell United Counties 6 Rainy River District Renfrew County Simcoe County 40 Stormont, Dundas & Glengarry United Counties Thunder Bay District 12 Timiskaming District Toronto Division 205 Waterloo Regional Municipality 17 Wellington County 18 York Regional Municipality 36

Trends over Time Average number of MAID procedures per month across Ontario is growing: April –Sept 2017 the provincial average was 71 cases/month In October there were 86, November 96 cases/month Since April 2017, there have been approximately 4 MAID procedures completed in WW each month Experience in other jurisdictions suggests that for every completed MAID procedure, there will be 4 additional requests for MAID 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

Trends over Time Average number of MAID procedures per month across Ontario since April 2017 is 71 (56, 67, 69, 86, 78) Since April 2017, there have been approximately 4 MAID procedures completed in WW each month Experience in other jurisdictions suggests that for every completed MAID procedure, there will be 4 additional requests for MAID

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

MAID in WWLHIN

Case #1 KW resident initial self-referral to provincial service in September 2017. Family physician involved re: suffering and probable depression. Physician looped back to patient for supports and to explore request. With high-level screening, patient considered by physician as not eligible because of probable long prognosis (nothing life-threatening now) depression influencing request and other situational/environmental factors. Re-referral to provincial line October 2017 and then again in January 2018 2 physicians collected Clinician Aid A written request but no follow up to arrange for eligibility assessments Raises question of high-level screening for eligibility and the patient’s entitlement to assessment even if probable ineligibility for service

Case #1 (cont’d) Next Steps: January 2018, local assessors will connect with family physician to determine next steps for eligibility assessment. Challenges: Limited resources to meet/ perform eligibility assessment when MRP concludes “ineligibility”. Should assessor(s) meet “ineligible” patients to satisfy repeat requests? If 1 or 2 eligibility assessments deem “ineligible” and patient re-refers in the context of no new circumstances, should new assessor (s) meet and if so, with what time frame? To maintain “integrity of independent assessment”, how much information should be shared with assessors?

Case #2 September 2017 resident with ALS asking ALS society to help navigate system for MAID information. The society guides patients by referring to local LHIN or to call provincial MAID Care Coordination Service Sept 27 ALS society manager called WWLHIN - LHIN left message with family to call back for intake and referral – no indication of family calling back to LHIN Patient has access to 2 assessments and has procedure planned for mid-January.

Case #2 (cont’d) HPC NP arranged to see family to ensure holistic needs met including symptom management and information needs Primary assessor not linked in with “team” for clinician support or for accounting for details pre, during and post procedure (i.e. family needs, IV access, grief and bereavement considerations). Discussion with ALS society to reinforce best response to family questions is to contact LHIN (or LHIN contacts directly) or provincial Line Contact with provincial line to ensure that self-identified regional assessors are linked in with LHIN team and resources to ensure holistic approach for family and providing clinician

Case #3 Cambridge resident receiving community HPC services. Enquiring about MAID for EOL. Early December 2017, wanted to pursue eligibility assessment – eligible. Explored all alternatives to MAID including hospice care. Difficulty coping at home at home, patient chose to pursue hospice care and a natural death. Transparent conversation with patient that MAID could not be pursued in hospice, however could be discharged to son’s home if he changed his mind. Discussion with hospice resource team prior to admission to review patient’s wishes and his intent to pursue natural death 2-3 weeks after hospice admission, elected to pursue discharge to son’s home in region

Case #3 (cont’d) This was an opportunity to have pre-emptive discussion with hospice team to clarify position on admission given patient’s disposition on natural death versus MAID death. Planning and coordination with LHIN, community provider and hospice teams essential – smooth transfer to son’s home achieved. Hospice team supported internally however anticipated emotional conflict and distress for some team members Challenge: how to support teams who experience conflict with transition of patient’s care from natural death when deciding to pursue MAID. (could be hospice, hospital, community providers, LHIN)

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