Thursday, June 23, 2016

NEW UpDated info Medical assistance in dying

Medical assistance in dying

Medical assistance in dying

Learn about medical assistance in dying, including the request process, who is eligible and who can provide the service. Also find out how the service is being carried out across Canada.

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Changes to the Criminal Code

In February 2015, the Supreme Court of Canada ruled in Carter v. Canada that parts of the Criminal Code would need to change to comply with the Canadian Charter of Rights and Freedoms. The parts that prohibited medical assistance in dying under certain conditions would no longer be valid. The Supreme Court gave the government until June 6, 2016, to create a new law.
In response, the federal government introduced legislation that allows eligible adults to request medical assistance in dying.

About medical assistance in dying

The service can only be legally provided by physicians and nurse practitioners (depending on the province or territory where you live).
There are 2 types of medical assistance in dying available to Canadians. They include where a physician or nurse practitioner:
  1. directly administers a substance that causes death, such as an injection of a drug
    • this is commonly called voluntary euthanasia
  2. gives or prescribes a drug that is self-administered to cause death
    • this is commonly known as medically-assisted suicide

Who is eligible for medical assistance in dying

In order to be eligible for medical assistance in dying, you must meet all of the following conditions. You must:
  • be eligible for health services funded by the federal government, or a province or territory
    • Generally, visitors to Canada are not eligible for medical assistance in dying.
  • be at least 18 years old and mentally competent (this means capable of making health care decisions for yourself);
  • have a grievous and irremediable medical condition;
  • make a request for medical assistance in dying which is not the result of outside pressure or influence; and,
  • give informed consent to receive medical assistance in dying (this means you have consented to medical assistance in dying after being given all of the information needed to make your decision. This includes information about:
    • your medical diagnosis
    • available forms of treatment
    • available options to relieve suffering, including palliative care

Grievous and irremediable medical condition

To be considered as having a grievous and irremediable medical condition, you must meetall of the following conditions. You must:
  • have a serious illness, disease or disability
  • be in an advanced state of decline that cannot be reversed
  • be suffering unbearably from your illness, disease, disability or state of decline; and,
  • be at a point where your natural death has become reasonably foreseeable, which takes into account all of your medical circumstances
You do not need to have a fatal or terminal condition to be eligible for medical assistance in dying.

Mental illness

People with a mental illness are eligible for medical assistance in dying as long as they meet all of the listed conditions.
However, you are not eligible for this service if:
  • you are suffering only from a mental illness;
  • death is not reasonably foreseeable when considering all the circumstances of your medical condition; or
  • a mental illness reduces your ability to make medical decisions
You must be mentally competent and capable of making decisions at the time that the service is provided. This is because the physician or nurse practitioner will ask you to confirm your choice right before administering medical assistance in dying. You are able to withdraw your consent at any time.

Additional research

There are more complex issues that are not addressed in the legislation. These issues have unique risks and considerations that need further examination. These issues are:
  • mature minors, which include young persons who:
    • have not reached adulthood (for this legislation, adulthood means 18 years of age)
    • are mature enough to consent to medical care
  • people who suffer from mental illness only
  • advance requests for this service to be carried out when a person is no longer able to:
    • make health care decisions
    • express their wishes
The new legislation requires the federal government to conduct further studies to examine the legal, medical and ethical questions around these situations. The results of these studies will help to inform future reviews of the legislation.

Who can provide assistance

Those who can provide medical assistance in dying services are:
  • physicians
  • nurse practitioners (in provinces where this is allowed)
Those who can help in providing medical assistance in dying include:
  • pharmacists
  • health care providers who help both physicians and nurse practitioners
  • family members or other people that you ask to help
These people can give or assist in providing the service without being charged under the criminal law. However, physicians, nurse practitioners and other people who are involved must follow:
  • the rules set out in the Criminal Code; and
  • applicable provincial and territorial health-related laws, rules and policies

Protecting the right of providers to act according to their beliefs and values

Not all health care providers will be comfortable with giving or helping to provide medical assistance in dying. The practice may not be consistent with a provider's beliefs and values. The legislation does not force any person to provide or help to provide medical assistance in dying.
However, this could create problems for patients who want to access medical assistance in dying.
The federal government will work with provinces and territories to develop a national coordination system for end-of-life care services. The system would guide people to information about where they can find help.

Process for requesting the service

The legislation contains safeguards to make sure those who ask for medical assistance in dying:
  • are eligible (this means they meet all of the listed conditions)
  • can give informed consent
  • are able to make health care decisions for themselves
  • request the service of their own free will
These safeguards will guide health care providers so that this service is carried out appropriately and protects people from abuse or misuse.
You may ask a health care provider about medical assistance in dying at any time.  However, the process for requesting medical assistance in dying requires the following steps to be completed.
  • Talk to your physician or nurse practitioner about end-of-life care options in relation to your medical condition or circumstances.
  • Your physician or nurse practitioner must make a determination that your medical condition is grievous and irremediable.
  • You must make and sign a written request or fill in and sign a form indicating you wish to seek medical assistance in dying.
    • If you are unable to write, another adult can sign the request on your behalf under your clear direction.
    • This adult must:
      • be at least 18 years of age;
      • understand what it means to request medical assistance in dying; and
      • not benefit from your death
  • Your request must be signed by 2 independent witnesses. An independent witness must be 18 years of age and understand what it means to request medical assistance in dying.
    • To be considered independent means that the witnesses cannot:
      • benefit from your death
      • be an owner or operator of a health care facility where you live or are receiving care
      • be directly involved in providing you with health or personal care
  • Your physician or nurse practitioner must make sure that you are eligible to receive medical assistance in dying according to all of the listed conditions.
  • A second physician or nurse practitioner must also provide a written second opinion confirming that you are eligible.
  • The physician or nurse practitioner providing the original assessment and the one giving the second opinion must be independent.
    • To be considered independent means that neither of them:
      • holds a position of authority over the other
      • is knowingly benefitting from your death
  • You must have waited a period of at least 10 days between signing your request and when the service is provided. An exception may be made if:
    • your death is fast approaching
    • you might soon lose your capacity to provide informed consent
  • You may withdraw your request at any time in the process. You are also not obligated to proceed with medical assistance in dying even if you are deemed eligible for the service. If you choose to continue, you will be given a final opportunity to withdraw your request just before receiving medical assistance in dying.

Who to contact for questions about access to medical assistance in dying:

Patients are encouraged to contact their physicians or nurse practitioners (if applicable) for questions about access.
Some provinces and territories may have developed otherinformation and coordination resources, and these will be posted here as available.
Physicians and nurse practitioners are encouraged to contact their provincial or territorial regulatory body for information about guidelines.

Where and how services are provided

Regardless of location, eligible Canadians can request medical assistance in dying. How and where this service will be offered will be determined by:
  • provinces and territories
  • the organizations that regulate medical professionals
  • medical institutions
Decisions about which drugs to use are part of the practice of medicine. This means they are guided by clinical guidelines and practices established by provinces and territories, or groups that regulate the practice of medicine.
Many of the drugs commonly used for this procedure are already marketed in Canada, and are prescribed for common purposes, such as pain control, anaesthesia, and nausea.  Health Canada, as the regulator of drug products, will work with partners, as appropriate, to help facilitate access to drugs for medical assistance in dying.

How governments work together

The federal government makes the criminal law.  The new legislation on medical assistance in dying will become part of the Criminal Code.  It states that medical assistance in dying is not a criminal offence when it is provided according to the conditions and safeguards in the law.
Provinces and territories must follow this new criminal law. However, they can create their own health-related laws or additional rules as long as they are consistent with what is in the criminal law. As long as these rules are within provincial power, they may address health and other aspects of medical assistance in dying, such as:
  • the use of specific forms to fill out
  • special medical training to provide the service
  • how information and data on the service are collected
  • rules or requirements for either type of medical assistance in dying
At the moment, the only province that has a specific law in place is Quebec. If you have questions about the law in your province or territory, you should consult their resources.

Comparison to Quebec's law

Key differences between the federal law and Quebec's law are:
These new changes to the Criminal Code allow both voluntary euthanasia and assisted suicide. Quebec's law only permits voluntary euthanasia.
There are also differences about who is eligible. For instance, under the new federal legislation, the unbearable suffering must be caused by a medical condition. This is not a strict requirement under Quebec's law.
Also, Quebec's law requires the patient to be "at the end of life." The new legislation indicates that medical assistance in dying can be provided to someone whose death is "reasonably foreseeable." There is not a required time frame before death occurs.

Additional commitments

The federal government is committed to the delivery of medical assistance in dying and to meeting the end-of-life care needs of Canadians. We will:
  • establish a process for monitoring (the collection of information) and reporting on medical assistance in dying
  • help Canadians find the services they need
  • respect the rights of health care providers who refuse to provide the service based on their beliefs and values
  • facilitate access to palliative and end-of-life care
Monitoring is important to give Canadians a clear picture of how the legislation is working. It helps Canadians understand the impact of the legislation. This could include information about:
  • the types of medical conditions that motivate requests
  • whether the safeguards in the law are working as intended
  • demographic information about people who request the service
  • whether there are regional differences in how the service is carried out across Canada
  • the number of requests made for medical assistance in dying (approved and not approved)
The federal government will work with provinces and territories to develop regulations to help us gather and analyze this type of information. It will also establish a temporary reporting system until a permanent process is developed.
These regulations will also respect and protect the privacy and confidentiality of the patients and providers that are involved in medical assistance in dying.
The federal government is working together with provinces and territories to establish a national coordination system for end-of-life care services.
If your health care provider chooses not to participate in medical assistance in dying because of their values or beliefs, the system would help you or your doctor find information about this service and other end-of-life care options.
Canadians have been united in their calls for better palliative and end-of-life care services. This is something the federal government also strongly supports. As part of a multi-year Health Accord, the federal government has committed to providing $3 billion over 4 years to improve home care, including palliative care.

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