Accessing end-of-life care in rural Ontario

Tuesday, November 21, 2017

How legislation about medical assistance in death affects palliative care

by Jim Algie

New federal law permitting medical assistance in death (MAID) has changed aspects of the palliative care provided by physicians in Canada. The law particularly affects the treatment of patients in the early stages of diagnosis with life-limiting illnesses, said Dr. Peter Tanuseputro, a leading researcher of palliative care and a family physician in Ottawa.

Legal changes that permit MAID affects the operators of hospice services too. It "changes the way we communicate" with patients and their families, Kim Woodland, the CEO of Matthews House Hospice in Alliston, said in a recent interview.

However, early national data shows few patients seek assisted death in hospices and that's the case in Alliston's facility.

Most people who seek help ending their lives die in hospital, according to an interim federal government report of first-year data issued by then-Health Minister Jane Philpott. The report tracks the deaths that followed royal assent of the federal law in June 2016 to the end of that calendar year. The federal numbers show a total of 507 medically assisted deaths between June 16 and Dec. 31, 2016.

Among those, about 50 per cent of people died in hospital, approximately 37 per cent died at home, about 6 per cent died in a long-term care or nursing home, and about 7 per cent died elsewhere, including palliative care hospices.

By the time they reach a residential hospice, most patients have made their choice or are ineligible for medically assisted deaths, Woodland and Tanuseputro said.

"We don't provide medical assistance in death as a service at our residential hospice," Woodland said. Most of those nearing death and preparing to enter hospice would not be considered eligible for medically assisted deaths, she added.

To be eligible, a person must be 18, mentally competent, have a grievous and irremediable condition, make a voluntary request and provide informed consent. The new law adds options once unavailable to dying people, Woodland said.

"It has allowed us to have more of a conversation about how people want to live out the end of their days," she said. "It gives all of us, the medical practitioners and (people in) the field of hospice and palliative care, a structure to guide us.

"How has it impacted our service, our residence? Only that we have a format and a structure and the rules of the game to talk about it," Woodland explained.

Tanuseputro is the author of a recent Canadian Medical Association Journal article on medically assisted death. He has not sought the training required to qualify as a provider of MAID and won't likely do so, he said in a Better Farming interview.

Ontario's Ministry of Health and Long-Term Care helps patients and clinicians get access to information and referrals to participating physicians, nurse practitioners and pharmacists. MAID arises frequently with a diagnosis of incurable illness, Tanuseputro said.

"I think, at the front line, it hits our practice in the sense that people are asking for it," he said. "When people are dying, they know that's an option, and I would say that maybe one in three or one in four people will bring it up and say, 'What are my options?'

"In some ways, it's tough for a palliative care physician to be asked the question. The spirit of palliative care is to provide a meaningful end-of-life experience."

Palliative care aims to provide effective control of pain and anxiety through techniques and support that can alleviate most concerns expressed by dying patients, he explained.

"They think they're going to suffer or they're afraid they're going to be a heavy burden to their family members," Tanuseputro said. "I think a lot of these are concerns that palliative care definitely tries to address.

"The question is, if you address all those concerns and you're still left with a person who has this almost existential angst about living and continuing to live, well ... I think that's beyond the job of palliative care.

"That's where palliative care or another MAID provider ... steps in. But I think there's a huge step there before MAID is pursued." BF