1. A RESIDENT’S RIGHT TO CHOOSE: Implementing the first MAID death in Ontario Long Term Care
Presented by: Jill Knowlton, Managing Director
Sarah Hind, Director of Clinical Services
Lisa Corrente, Partner, Torkin Manes LLP
Mrs. Wendy Taylor, Family Member
April

2. Overview John’s Story Receiving the Request
Examining Values and the Paradigm Shift
Making a Referral
Legislation, Policy + Legal Requirements
Conscientious Objector Process
Focus on the Resident + Supporting the Family
Support to Co residents, Staff and Others
Current Status of Legislation + Legal Challenges

3. John Taylor’s Story
Passion for Rock Climbing

4. John Taylor’s Story
A Daughter’s
Wedding

5. John Taylor’s Story
Solving a
Problem

6. John Taylor’s Story
Together from beginning to end

7. The Request March 28, 2016: First request for a Meeting Exploratory
April, 2016: Meeting with Medical Director
Outlining the Home’s position
Discussion of The Carter v. Canada Decision 2015
SCC suspended declaration of constitutional invalidity
until June 6, 2016
May, 2016: Third Meeting –John’s Position is Clear
LTC is “ground zero” for a death at home

8. The Request June 6, 2016: Fourth Meeting
Disappointment – assisted dying is legal…BUT
Begin discussion around applying to Superior Court
for an order allowing PAD on meeting Carter criteria
Lawyer now involved ---Court order is a practical
necessity
June 17, 2016: Fifth Meeting
Federal Bill C-14 receives Royal Assent
Celebration
July 1, 2016 to August 3, 2016: Multiple Meetings
Plan put in motion
Assisted death August 3

9. Why Delay? Delays from request to implementation are problematic.
Gaps in legislation and absence of regulations
Home not ready: policy, forms, education, supports
Vacations: Hospital Clinicians, Home Staff and Family
Requirement for venous access: appointment at hospital for PICC line as IV access was not achievable
Medication orders and pharmacy access to drugs

10. Medication Schedule Anxiolytic Midazolam 1 mg/mL concentration
Provide mL bottles
Require 2 kits of 10 mg each (2nd kit to be returned unused)
Need mL syringes
 Local Anaesthetic
Lidocaine without epinephrine 20 mg/mL concentration
2 mL or 40 mg in a syringe
Provide 1

11. Medication Schedule Coma Inducing Agent
Propofol 10 mg/mL concentration
Provide mL bottles
Require 2 kits of 1000 mg each (2nd kit to be returned unused)
Need mL syringes
Neuromuscular Blocker
Rocuronium bromide 10 mg/mL concentration
Provide mL bottles
Require 2 kits of 200 mg each (2nd kit to be returned unused)
Need mL syringes
 Also need NaCl 0.9% saline solution (1 litre) with IV tubing and extra 10 mL syringes and antiseptic swabs.

12. Role of Senior Leader
MAID Lead – central point of contact: info in and out
Liaise with Medical Director, Attending Physicians, management team, corporate office, staff, resident, family, MOH representatives, Chief Coroner’s office, legal counsel
Guide and direct
Ensuring policy in place and is known
Ensuring external practitioners follow the Home’s policies
Ensuring a process to conscientiously object
Ensuring support to residents, families, staff and others

13. Paradigm Shift Organizational + Individual Values and Beliefs
Do No Harm Assisted Suicide
Resident Rights Resident Rights
MAID Values and Beliefs

14. Examine STAFF – 2 sessions/1 week apart around the clock
Small groups (no more than 8 to 10)
Maximum 30 minutes
By home area team or department – support one another, sit together
Make it safe – create a “No Risk Table”
Start with required information such as the legislation; resident rights; CNO Guidelines; RNAO/RPNAO; Home’s policy and other resources
Review the Home’s values
Leave with a question: what are your personal values and beliefs?
Provide mechanism for questions or further discussion and consider access to all shifts

15. Examine Staff: part 2 - Reflection
One week later reconvene in small groups
Sit together
Use open ended questions
Seek out responses to, “I feel, I sense, I value/believe”
Be prepared to start the conversation
Revisit key information – right to be a conscientious objector + not necessary to state why/free from harassment
Focus on resident’s right to privacy
Make it safe + provide supports

16. Conscientious Objector
Explain what this means
Distribute forms and have them readily available
Create a process that is confidential for return of forms
Create a tracking sheet
Organize the schedule for the day well in advance
Consider allowing personal days, vacation days
Consider that staff may change their minds
Consider the safety of other residents – may require you have extra staff on that day

17. Emotional Pitfalls Talking the resident out of it
Talking to family members and visitors and attempting to influence them to change the resident’s mind
Harassing co workers who conscientiously object
Holding Prayer Circles onsite and through social media
Calling in sick
Not respecting the resident’s privacy
Attempting to influence co residents
Attempting to influence co workers

18. Residents and Families
We are a Home
Consider:
Education for residents and families
Opportunity to discuss personal values and beliefs
Opportunity to “conscientiously object”
Informing them of the day’s routine; any staff changes
Providing support and grief counselling
Opportunity to be part of Honour Guard

19. Policy Early days: Interim
Absence of regulations and gaps in legislation
Development – Relied upon:
Interim guidelines published by CPSO, CNO, OCP
CMA Principles-based Recommendations
Discussion Papers by Joint Centre for Bioethics, U of T
Provincial-Territorial Expert Advisory Group on PAD
Report of the Special Joint Committee on PAD
Palliative and End-of-Life Care Provincial Roundtable Report

20. Policy
Consultation with the Office of the Chief Coroner with special mention of Dr. Dirk Huyer, Chief Coroner and the Ministry of Health and Long Term Care
Reviewed by our lawyer with input received
Included required documentation forms supplied by the Ministry of Health: “Clinician Aides”
Consultation with feedback requested from Medical Director, Consultant Pharmacist and members of the Interprofessional Team
Circulated to staff as “Interim”

21. External Practitioners
Ensure:
Clear understanding of the Home’s policy and requirements for documentation
Informed of LTCHA and associated regulations that must be followed
Informed of primary contact (ie. MAID Lead)
Provision of medication orders to pharmacist early
Provision of list of supplies and equipment required from the Home
Communication with the Resident, Family (with consent) and Home Staff

22. LTCHA + Regulations Consider:
Role of attending physician and external consultants
(O Reg. s. 83)
Obtaining MAID drugs from the Home’s pharmacy
(O Reg. s. 122)
Documentation requirements on the Resident’s Health Record (O Reg. s. 231)
Certification of Forms (LTCHA 2007 s. 80)
Safe storage and destruction of MAID drugs (O Reg. s. 129, 136)
Institutional Patient Death Record reporting (Coroners Act)
Critical Incident reporting (O Reg. s. 7)

23. Awaiting passage of Bill C-14 by the Senate
The Real Event
The request is made known to the Home’s staff
The Medical Director with the Managing Director meet with the resident and confirm request
The resident’s concerns about terminal condition are explored
Alternate treatment options are shared such as terminal sedation and dialing down the respirator
This meeting is documented in the resident’s chart
Awaiting passage of Bill C-14 by the Senate

24. The Real Event
Home considers its ability to implement MAID death in the
absence of regulations and gaps in legislation. Resident
rejects death in hospital.
Home consults with lawyer and advised that it best to
proceed and focus on the Resident’s Right to die at Home.
Resident consults his ethicist and physician contacts at the
hospital (made his own referral).

25. The Real Event Two physicians from the hospital who are considered
independent of each other schedule an appointment to
meet with resident in the Home. Arrive with hospital policy,
forms in hand. Chart entry is not made on the health record
in the Home.
Resident eligibility for MAID is confirmed and informed
consent obtained, primary medical practitioner confirms
eligibility and reflection period followed by secondary
medical practitioner
Still NO Notes on the Health Record

26. The Real Event
7. MAID Lead meets with resident. Informs of requirements of
the Home. Director of Clinical Services contacts lead physician
and explains documentation requirements and requests that
the Home’s forms are completed and faxed to the Home.
8. Clinician forms A, B and C are now executed.
9. Notes being added to the Health Record.
10. Attending physician is added as a cc to all communications.
11. Drugs are ordered from the Home’s contracted pharmacy.
12. Drugs are stored in separately, locked location – 2 kits

27. Reporting to the MOHLTC
Lawyer communicates with the MOHLTC on behalf of the Home informing them of the MAID request and eligibility.
MOHLTC advises that the Home ensure the MAID request is in the plan of care; advises that the Home’s concerns regarding certain regulations will be overlooked with the focus on the Resident’s Right to an assisted death at Home.

28. Notifying the Coroner Lawyer communicates with Chief Coroner
New Interim process in place until regulatory changes are made – due Jan 1, 2017.
Only 3 coroners handling death by MAID – Dr. Huyer as the chief and 2 of his deputies – this has CHANGED
Do not complete IPDR - emphasized
The MD who administers MAID will notify the Coroner
Home must document in the resident health record that the MD made the call and the report to the office of the Chief Coroner

29. The Real Event
Home prepares all documents relating to the request for MAID:
Chart notes
Consults
Opinions
This is all faxed to the office of the Chief Coroner.
Note: the request for MAID, the assessment for eligibility and 2 witness statements have been confirmed by the Chief Coroner as required on the Home’s chart.

30. The Real Event
Coroner will call the family and ask if funeral home arrangements are made to have the body transferred to a regional pathology centre. If no funeral arrangements, then the Coroner’s office will make arrangements at their expense to transport the body to the regional pathology centre.
Arm band identifying the resident must be on the body. Have one ready to put on the body.
Coroner will examine the body at the pathology unit and extract a blood sample – NOW: at the discretion of the Coroner

31. The Real Event Won’t do anything more intrusive unless needed
Will have the body for about 24 hours and notify the family when it is ready to be moved to the funeral home
Death Certificate will be completed by the Coroner at the Regional Pathology Centre and will state the cause of death as: SUICIDE. Second level cause will be the disease.
The Home is to report the cause of death as Suicide to Service Ontario.
It is not reported as a Critical Incident.

32. Best Practices
Walk through day’s events with team two to three days in advance and with family one day in advance
Prepare for the final question
Add additional PSW and registered staff on the Home Area
Provide more frequent breaks for staff involved if time out is required
Assign a senior staff member to the family and visitors ensuring they are supported
Hospitality – stay over suite available, refreshments and meals, dedicated room for visiting if large numbers expected
Flowers for the family

33. Best Practices
Honour the resident’s last wishes – Scotch Party! Persons present at time of death and request passage to be read at Honour Guard
Communicate daily with your care team members, resident and family
Provide a point of contact for staff for more information
Create a checklist for equipment, supplies and required documentation
Confirm all documentation is complete prior to clinicians leaving the Home
Provide a structured debrief for staff and ongoing
Invite residents and visitors to be part of the Honour Guard

34. Lessons Learned
Provide education to residents and families so they are generally informed about MAID
Provide supports for residents who may hold incompatible values and beliefs
Plan to have activities off the Home Area for residents who wish to be out of the area
Provide follow up support and grief counselling to
co residents
Support residents to memorialize the deceased person

35. Challenge
“Be prepared for MAID and what else the future holds.” For John, he showed his courage and strength by ensuring MAID was available in LTC. His disease controlled him but he would not allow it to control his final decision – his death. He wanted this to be his LEGACY.

36. MEDICAL ASSISTANCE IN DYING:
The Past, the Present and the Future
Together We Care – April 5, 2017
Presented by: Lisa Corrente

37. Overview The Past : Lessons Learned
The Present: Recent Statistics and Ongoing Legal Challenges/Reviews
The Future: Bill 84

38. The Past: Lessons Learned
Timelines
Typical timeline – on average, 2 weeks from signing the patient’s written request, including:
assessments for eligibility by 2 independent practitioners
10-day reflection period
In my experience, timelines have been longer for long-term care/retirement homes
transfers to hospital (e.g. PICC line)
conscientious objections / availability
resident’s wishes

39. The Past: Lessons Learned
Refection Period
Must be 10 clear days between resident’s written request and provision of medication, unless:
resident’s loss of capacity or death is imminent
There have been cases in which medical practitioners have improperly shortened reflection period in other circumstances
e.g. patient was in too much pain, patient wanted treatment earlier
Home’s MAiD lead has to stay informed and oversee process to ensure compliance

40. The Past: Lessons Learned
Witnesses
Requirement for 2 independent witnesses
Witnesses cannot:
directly provide health care services or personal care to the resident
be the owner or operator of any health care facility
know or believe they are a beneficiary under a will (excludes most family members)
Difficult to identify independent witnesses in LTC/retirement settings?
Friends (willingness, availability, etc.)
Health care provider in the home, if they do not own the home and are not directly involved in resident’s health care or personal care
Home’s policy
Staff feeling pressured by resident requests

41. The Past: Lessons Learned
Conscientious Objections
Not uncommon for medical practitioner (e.g. medical director or attending physician) or nurse practitioner to conscientiously object
moral objection
lack knowledge or experience
uncertainty regarding “natural death has become reasonably foreseeable”
Use of Clinician Referral Service or resident’s specialist (outside of home)
Need to familiarize outside practitioners of home’s obligations and policies

42. The Past: Lessons Learned
Record-Keeping
Coroner’s Office has expressed concern about variation in record- keeping
reduced amount of documentation
insufficient detail
Medical and nurse practitioners have not documented effective referrals
Use of Ministry’s Clinician Aids has been helpful – keep in resident’s file
Document process and interactions in progress notes and plan of care
Outside practitioners should be documenting in resident’s records

43. The Past: Lessons Learned
Drug Protocol
All health care providers involved in MAiD process must coordinate and communicate with one another
appropriate drug protocol (CPSO website)
early notification of the pharmacy service provider
No self-administration within the home

44. The Present: Most Recent Statistics
Sex:
Female: 151
Male: 154
Age:
Average Age:
Youngest: 35
Oldest: 101
Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data

45. The Present: Most Recent Statistics
County
MAiD Cases
Brant County
< 5
Bruce County
Cochrane District
Dufferin County
Durham Regional Municipality 5
Elgin County
Essex County
Frontenac County 12
Grey County
Haldimand-Norfolk Regional Municipality
Halton Regional Municipality 11
Hamilton Division 17
Hastings County
Lambton County
Lanark County
Leeds & Grenville United Counties 8
Kawartha Lakes Division
Kenora District
Middlesex County 13
County
MAiD Cases
Muskoka District Municipality
< 5
Niagara Regional Municipality 9
Nipissing District
Northumberland County
Ottawa Division 35
Parry Sound District
Peel Regional Municipality 17
Peterborough County 10
Prescott & Russell United Counties
Rainy River District
Simcoe County 13
Stormont, Dundas & Glengarry United Counties
Greater Sudbury Division
Timiskaming District
Toronto Division 81
Thunder Bay District
Waterloo Regional Municipality 6
Wellington County
York Regional Municipality 15

46. The Present: Legal Challenges/Reviews
Lamb v. Canada – constitutional challenge to federal legislation filed by the BCCLA
Faith groups representing over 4,700 Christian doctors across Canada have launched a judicial review application in the Ontario Divisional Court arguing that the CPSO’s MAiD policy, requiring effective referrals to be made by physicians who have a conscientious objection, is a Charter violation.
Council of Canadian Academies is undertaking a review of circumstances outside of the current scope of MAiD:
requests by mature minors
advance requests
requests where mental illness is the sole underlying medical condition
Reports expected in 2018

47. The Future: Bill 84
Medical Assistance in Dying Statute Law Amendment Act, 2017
Proposed provincial legislation which provides some clarity regarding decriminalization of medically assisted death
Introduced on December 7, 2016
Passed 2nd Reading – March 9, 2017
Standing Committee on Finance & Economic Affairs held public meetings on March 23 and 30, 2017
If passed, will amend 6 Ontario statutes
No amendments proposed to the LTCHA or RHA

48. The Future: Bill 84 Excellent Care for All Act
The fact that a person received MAiD cannot be invoked to deny a benefit or other sum provided under contract or statute
e.g. life insurance benefits, WSIB survivor benefits, pension benefits
No action or other proceeding for damages can be commenced against a physician or nurse practitioner or any other person assisting them for acts or omissions done in good faith relating to MAiD
except an action or proceedings based in alleged negligence
no immunity from civil action against health facilities

49. The Future: Bill 84 Workplace Safety & Insurance Act FIPPA & MFIPPA
Amended to state that the cause of death of a person who receives MAiD will be the underlying illness or injury
FIPPA & MFIPPA
Acts do not apply to identifying information relating to MAiD
Amendments would protect against access to information requests identifying clinicians and “facilities” providing MAiD
Term “facility” not defined in Bill or existing legislation
MFIPPA covers municipally-run LTC homes
PHIPA continues to apply to homes

50. The Future: Bill 84 Coroners Act
Where a person dies from MAiD, physician or NP who administered treatment must notify the coroner
Must provide any information about the facts and circumstances relating to the death that Coroner considers necessary
Any other person with knowledge of the death must provide such information on the request of the coroner
Coroner will have discretion as to whether an investigation will ensue into the circumstances of death
Based on the information provided
Role of the coroner in MAiD to be reviewed by Minister of MCSCS within 2 years

51. The Future: Bill 84 Vital Statistics Act
Amendments set requirements respecting coroner’s documentation of MAiD deaths
Clarifies that coroner does not need to sign the medical certificate of death for MAiD deaths, unless the coroner investigates

52. Ontario’s Care Coordination Service
Province is proposing to establish a Care Coordination Service
to assist patients and caregivers in accessing additional information and services for MAiD and other end-of-life options
Service would supplement the Clinician Referral Service
MOH to share further information about CCS in early 2017

53. Outstanding Issues
Amendments to the LTCHA and RHA in order to “fill-in the gaps”
Conscientious objections to providing MAiD by faith-based homes
Nurse practitioners prescribing narcotics
Data and information gathering

54. Lisa Corrente Partner, Employment & Labour Group/Health Law Group