Assisted Dying: An Update June 2016 Sandra Andreychuk, BScN, MHSc, MSc Clinical Ethicist Hamilton Health Sciences

We do not see things as they are. We see them as we are. - The Talmud

Objectives Review Current Legal Framework for Assisted Dying (AD) Discuss current professional guidelines (MD,RN,SW) Review Values associated with AD Provide examples of a public and catholic hospitals approach to AD Create space to reflect on our personal feelings and values of AD

Things to Consider…. Beliefs and values about death and dying are deeply personal There is no intrinsically right or wrong way to feel about Assisted Dying (AD) No one will be forced to participate in AD Most patients who inquire about AD never receive it; they select other EoL options Only capable, consenting patients who meet specific criteria will receive AD Patients frequently make choices we disagree with personally/professionally

Current legal framework Decriminalization of assisted dying on – Carter versus Canada In the interim…individual court applications Awaiting senates approval of Bill C14

Decriminalization: Carter vs Canada whether Criminal Code unjustifiably infringes on the Canadian Charter of Rights and Freedoms prohibition lifted for a competent adult person who clearly consents to the termination of life and has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. suspended 12 months, extension granted: June 06, 2016 patients may access PAD in the interim period by applying for an exemption to Superior Court of Ontario The decision was released on February 6th 2015. And it was not signed, which means that all judges were unanimous in the decision. The legal process was lengthy and started in BC by Kay Carter, a woman suffering from degenerative spinal stenosis, and Gloria Taylor, a woman suffering from amyotrophic lateral sclerosis (ALS). The central legal was question around the constitutionality of the Criminal Code prohibitions against physician assisted dying (PAD), specifically Sections 14 and 241(b) of the Criminal Code unjustifiably infringe s. 7 of the Canadian Charter of Rights and Freedoms and are of no force or effect to the extent that they prohibit The prohibition remains intact except for PAD when the patient: Is an adult; Is competent; Clearly consents to the termination of life; Has a grievous and irremediable medical condition (including an illness, disease or disability); The grievous and irremediable medical condition causes enduring suffering; and The enduring suffering is intolerable to the individual in the circumstances of his or her condition.

Summary of Carter vs Canada Carter Feb 6 2015 – SCC struck down two section of the Criminal Code as unconstitutional, in certain circumstances, but put a moratorium on that for one year so that new legislation could be put into place. Carter Jan 16th 2016 – federal gov’t applied for further extension, and was granted 4 more months (to June 6th)

Criteria for provision of AD Competent adult; Has a grievous and irremediable medical conditions ( including an illness, disease or disability); Which causes enduring intolerable suffering; Which cannot be alleviated by any treatment available which the person finds acceptable; Consents to the termination of life, with the assistance of a physician

Interim Court Requirements Individuals who met the criteria could bring an application to the Superior Courts seeking an exemption from the provisions of the CC. Affidavits from : The applicant seeking the relief Applicants attending physician re: conditions and capacity consulting Psychiatrist re: capacity Physician willing to assist (if different from attending)

Bill C-14 – an act to amend the criminal code and to make related amendments to other Acts For competent adults 18 or older Request in writing with two independent witnesses Eligibility confirmed by 2 MD / NP’s, independently A waiting period “of reflection” 10 days or less is loss of capacity imminent A rigorous post-hoc reporting and review process No appeal mechanism (for those denied) Extension of exception to other persons who provide assistance to the MD/NP Commitment to providing other EOL strategies Commitment to improving mental health and dementia care

Bill C -14 – what was not expected The definition of “grievous and irremediable medical condition” includes the requirement that “natural death has become reasonable foreseeable. Taking into account all their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining”

Bill C -14 – what was not expected Both physicians and NP’s are extended the same exceptions in providing medical care in providing AD Medical assistance in dying must be provided with reasonable knowledge, care and skill, an in accordance with any applicable provincial laws, rules, or standards Reflection period of 15 days (now 10) (or less if the patient’s death or incapacity is imminent)- expected it to be more flexible, tailored to the specific circumstances

CPSO Policy Highlights Outlines same criteria as SCC: Is an adult; Is competent; Clearly consents to the termination of life; Has a grievous and irremediable medical condition (including an illness, disease or disability); The grievous and irremediable medical condition causes enduring suffering; and The enduring suffering is intolerable to the individual in the circumstances of his or her condition. College and court noted that “irremediable does not require the patient to undertake treatments that are not acceptable to the individual”.

CPSO Policy Highlights College maintains OBLIGATION to make an Effective Referral College outlines process for several assessments, waits and criteria to meet after a request for PAD Province has provided 1-800 number for referral

Conscientious Objection When an individual HCP, due to matters of conscience, elects not to participate in assisted dying. The level of comfort and support an individual HCP may or may not be willing to provide will likely vary in scope. i.e, HCP may be comfortable supporting a range of activities such as having an exploratory discussion or providing a second medical opinion but may not be willing to prescribe or administer assisted dying; other individual healthcare professionals may wish to limit their involvement with assisted dying to the full extent permitted by their professional colleges or employer.

Values Accountability: decision makers are responsible for their actions; Collaboration: Partnering with relevant stakeholders in a respectful and accountable manner Dignity: The state or quality of being worthy of honour and respect Equity: like cases are treated similarly and dissimilar cases treated in a manner that reflects the dissimilarities; Respect: Recognition of the individual's right to make individual choices according to their values and beliefs

Values Transparency: The quality of acting in a way that ensures that the processes by which decisions are made are open to scrutiny, and the associated rationales are publicly accessible. Solidarity: interpersonal-level: commitment to help people get through all facets surrounding requests, provision of assisted dying and the aftermath; organizational-level: commitment on behalf of the organization to follow through and be supportive to both staff members that support the provision of MAID and those that conscientiously object. Compassion: a quality fundamental to the relationship between the patient and the provider. A deep awareness of the suffering of another coupled with a wish to relieve it

I may not agree with their End of Life decisions, but as long as I respect their wishes I think I’d be okay with that.

One Public Hospital’s approach to Assisted Dying recognizes the provision of assisted dying to a patient meeting Eligibility Criteria as a legal option within a participating publicly funded hospital. supports patient and family centered care and acknowledges the right of eligible patients to choose assisted dying as a healthcare option. Local Health System Integration Act S.O. 2006, s28,(2)

One Public Hospital’s approach to Assisted Dying Provide a single point of access for referrals and information about AD for physicians/patients/staff. Provide coaching to clinical teams responding to patient inquiries Support formal assessment of patients Provide second opinions Facilitate AD for eligible patients (with appropriate consultation and in collaboration with the patient’s healthcare team, including community resources such as the family physician) Develop/adapt appropriate resources, policies and procedures to govern PAD practice

Approach to End of life Care in a Catholic Hospital

Catholic moral tradition Two Clear moral truths in end-of-life care (Catholic Health Alliance of Canada) Exceptionless prohibition against the direct and deliberate hastening of death in order to end suffering – do not intentionally hasten death The lack of an obligation to use all means possible to extend life in all cases – do not seek an over-zealous and burdensome prolongation of life

Reflecting on my responsibilities? Reflect: how will I respond to a patient inquiry about AD… Respect personal beliefs of self and colleagues, honoring moral diversity of the workforce Create safe space for discussion by focusing on shared values Respecting patient autonomy, ensuring informed consent Relieving suffering Reducing harm Offering choices Refer patients who inquire about AD to MRP Support patients and families in their suffering

Pausing… What do I feel about assisted dying? Where do my feelings come from? What are my values and how can these enable me to respond to this change with compassion?

Values-based conversation means… Assuming nothing Your beliefs/values may not be shared by others; inviting others to speak authentically Valuing Moral Diversity… Everyone’s perspective has something to add to our collective understanding; holding our truths with humility Creating Space… To wonder, to be surprised; being open to learning

Questions: choose 2 to discuss What most worries you about assisted dying in your context? What are your hopes/aspirations for assisted dying in your context? What do you see as your responsibilities in a system where assisted dying is an option for patients, given your role/scope? What supports would you want in place to ensure patients seeking assisted dying receive safe/high quality/ compassionate care? What supports would you want in place for your clinical colleagues who participate in assisted dying? Other burning questions?

Pausing… What do I now know? What action might I take?

Questions or Comments?