The question: My father was in the advanced stages of prostate cancer and wanted a medically assisted death. He was told he needed the approval of two health-care providers. One said yes, but the other said no because he "was not in any distress." But that decision was so wrong. My father was a very stoic man, and was not one to complain. Did the doctor want him to break down in tears and beg to be put to death? My father died two weeks later in a hospice – instead of his home, the place where he wanted to die.
The answer: It has been over a year and a half since Parliament passed a law that makes medical assistance in dying – called MAID for short – legal across Canada. The story you tell reflects one of the many challenges in creating a standardized system to handle these requests and to ensure that patients and their families are properly informed.
One key failing in your father's case is that he was not apparently told he could have asked for another assessment after the second MAID assessor turned him down. If another assessor had agreed that he was eligible, he could have proceeded with an assisted death.
It's impossible to say whether his assessors were unaware he had this option or simply failed to mention it.
Whatever the case, "we need to do a better job educating health-care providers about what they must be disclosing to patients," says Jocelyn Downie, a professor in the faculties of law and medicine at Dalhousie University in Halifax.
In the meantime, it's certainly worthwhile reviewing how the process is supposed to work.
The federal law requires that patients must undergo two independent medical assessments, which can be done by either doctors or nurse practitioners. The assessors determine if the person meets all the criteria for MAID.
For starters, a patient must be 18 years or older and mentally competent to make the decision.
The person must also have a "grievous and irremediable medical condition," which is defined as:
- A serious and incurable illness, disease or disability;
- An advanced state of irreversible decline in capabilities;
- Natural death is reasonably foreseeable;
- The patient is experiencing physical or psychological suffering that is enduring and intolerable – and it can’t be relieved under conditions that the individual considers acceptable.
Certain requirements are fairly straightforward. Late-stage cancer would clearly meet the definition of an incurable illness.
But there is room for interpretation on some of the other eligibility criteria, says Sally Bean, an ethicist and policy adviser at Sunnybrook Health Sciences Centre in Toronto.
If your father was "stoic" and didn't express his true feelings, the assessor may have thought, rightly or wrongly, that his suffering was tolerable rather than intolerable. In that case, the assessor might have deemed him ineligible for MAID.
During this review process, the assessor may have asked if palliative sedation would be acceptable to your father – he would essentially be made unconscious during his final days of life. If he agreed, the assessor might have concluded his suffering could be relieved by means acceptable to him and so he wouldn't qualify for MAID.
Ms. Bean says some assessors could be reading the MAID requirements very narrowly. "They may be trying to follow the letter of the law and I can understand that approach, especially when dealing with an exception to the criminal code."
However, she adds there is an obligation on the part of the assessor to "make sure the patient is informed and understands why certain questions are being asked, what they mean and the implications" of how the person answers them.
Medically assisted death is still relatively new in Canada and there's likely to be some variation in how it is carried out, says Ms. Bean.
That variation, though, is expected to diminish with efforts to create a standardized approach.
"We are trying to establish best medical practices so there is consistency across the country," says Stefanie Green, president of the Canadian Association of MAID Assessors and Providers (CAMAP) in Victoria.
Aside from helping health-care providers, CAMAP also offers guidance to patients.
"If people are confused about MAID, they can get in touch with us through our website – camapcanada.ca – and we will direct them to an appropriate MAID co-ordination centre," says Dr. Green.
Paul Taylor is a patient navigation adviser at Sunnybrook Health Sciences Centre. He is a former health editor of The Globe and Mail. You can find him on Twitter @epaultaylor and online at Sunnybrook's Your Health Matters.