1. Medical Aid in Dying: Developing a Framework October 27 2015 Hart House

2. Some History Hippocrates – Utterly opposed to all of this Mostly discussed by physicians and lawyers Similar to small pox inoculation – Lady Mary Wortley Montagu 1715 – Used by royalty for 100 years – before it was adopted by general population Used secretly by the very well off for generations – Annalee Fadiman Jacqueline Kennedy. Linda McCartney,

3. Canada: Primary Care &Hospital Services Canadian services out of balance – Hospital Service and Primary Care Few community based services – Home care – Home help – Transport – Underserved Home palliative care This service must sit with our existing services and we must make it as simple and transparent as possible for patients and their families

4. What Patients Know When they are ready to die – This does not always have to certified by a doctor – The doctor has to ask if she can do it Many Speakers: the debate included doctors and lawyers – Now also Patients and Families Setting rules to exclude physician assisted death can exclude patients who have so died – Imminent Death requirement excludes Sue Rodriguez and Annalee Fadiman

5. Patient and Family Decisions You don’t want to let someone to die just because they will suffer for a long time in a drafty hospital corridor (Why not?) Instead you must be given adequate palliative care (How likely is this in Quebec’s overcrowded emergency rooms) Can successful palliative care include early assisted death Is it an appropriate objective to reduce requests for Dr assisted death to 1 or 2 times a year

6. Roles Role of Patient herself Role of family: Make decision with Role of family physician: To help person and family with decision Role of Specialist: to consult about condition Role of physician who administers death Role of other professionals eg nurses and other therapists Illegal to avoid this – e.g Switzerland where individuals and families can simply buy a service

7. Challenges There will be challenges Excessively complex procedures that stop help Humanitarians who don’t follow procedures People who are grievously or irremediably ill only: Who decides What does it meant to endure serious suffering Assisted suicide in Isolated communities Objective to exclude which groups and why? – People tired of living Physician attitudes should we be more critical?

8. Rates of Medically Assisted Suicide Going up annually Are medically related suicide rate going up Are familial aid suicides occurring? Is it necessary to have a review board? The law is a tortoise: how do you do this in good time?

9. What about special populations Isolated communities (high rate of existing suicide) Prisoners ( No hope of freedom No DNR) Tired of Living (95 year old man now blind and immobile) At the point of diagnosis of an inevitable death (high stage cancer) At the point of diagnosis of dementia (Fadiman) At the pointo diagnosis of severe disability (Rodriguez)

10. We Must Include Patients as Partners In developing our policies and practices We should be less focused on physician and lawyer issues We must get a better understanding of patient and family perceived needs about death and dying We must get a better idea of actual practices in our country and learn from them