The number of Ontario clinicians registered to participate in medical aid in dying has fallen dramatically since the provincial government set up a new co-ordination program that was supposed to improve access for the grievously ill while easing the moral burden on physicians who object to referring patients for assisted death.
Only 74 doctors and nurse practitioners have signed up for the new care co-ordination service, down from 181 when the Ontario Ministry of Health and Long-Term Care shut down its old confidential referral list of medical-aid-in-dying (MAID) providers on May 31.
The provincial government has expressed confidence that more clinicians will register as the new service matures, but front-line providers say the shortcomings of the care co-ordination service are turning off some doctors, which could make it harder for eligible patients to find someone to help them end their lives. The service connects patients to doctors willing to help them, but does not make the arrangements for the whole process.
"I have great concerns about how it's supposed to operate, and that's why I didn't register," said Chantal Perrot, a Toronto family doctor who has been involved in 20 assisted-death cases. "I am passionately committed to providing MAID, and to these patients, but the care co-ordination service that the province rolled out at the end of May is not a care co-ordination service," she said.
"It's a matchmaking service that offers no support for physicians and nurse practitioners doing this work."
The potential problems in Ontario are the latest example of the practical hiccups that have marred the implementation of Canada's assisted-dying law.
The Globe and Mail reported this week that some MAID providers in British Columbia are bowing out because they say new fees for the service are so low they cannot afford to continue accepting referrals, especially in cases that require travel. In Nova Scotia, about half the claims filed so far for assisted death are stuck in processing.
Ontario's new care co-ordination service, launched in late May, was supposed to answer calls for Canada's most populous province to adopt the so-called Alberta model.
Alberta's MAID system, which is generally regarded as one of the best in the country, has four care co-ordinators, all of them nurses, who act as central intake officers and arrange all aspects of the end-of-life procedure, including finding a doctor and two assessors, lining up the medications, scheduling the death and helping with the voluminous official paperwork.
The approach has worked well for both MAID providers and for doctors who refuse on moral grounds to refer patients for assisted death – those conscientious objectors can give their patients contact information for the co-ordinating service and avoid a formal referral.
But Ontario's new system is not a co-ordination service, according to James Downar, a critical- and palliative-care doctor at Toronto's University Health Network.
In the Ontario system, a toll-free number operated by Telehealth Ontario between 9 a.m. and 5 p.m. on weekdays puts self-referring patients (or their caregivers) in touch with nurses who do the initial screening and connect them to a doctor or nurse practitioner on the registry. The toll-free line will be open 24 hours a day starting on Sept. 1.
There are no Alberta-style care co-ordinators, at least for now.
"I can tell you for a fact there are many people who made a conscious decision not to sign up for the new service who were on the old roster because of the fact that this new care co-ordination service is not as comprehensive as the Alberta one," said Dr. Downar, who is also a member of the physicians advisory council for the advocacy group Dying with Dignity Canada.
Meantime, some conscientious objectors say the new toll-free number does not alleviate their chief concern: That Kathleen Wynne's Liberal government refused to enshrine conscience protection for physicians in its MAID legislation.
The government also intervened in support of the College of Physicians and Surgeons of Ontario (CPSO) last month as the medical regulator defended in court its policy that doctors must provide an "effective referral" for patients seeking assisted deaths.
A decision in that case is expected later this year.
Mark D'Souza, an emergency-room doctor who opposes MAID and quit providing in-home palliative care in Scarborough after Ontario passed its law in the spring, said the new care co-ordination line is not good enough so long as the CPSO's effective-referral rule stays in place.
"If [patients] complain that I'm not the one picking up the phone [to do the referral], my licence would be in jeopardy," he said. "That's not a scenario I want to expose myself to, and that's why I left palliative care."
In an e-mailed statement, Health Minister Eric Hoskins acknowledged more needs to be done.
"We're continuing to work alongside our partners to further develop the care co-ordination service so that patients who want to access this new service receive the most seamless, prompt and responsive support as possible," he said.
Not all of the 181 clinicians on the old referral list as of May 31 were providing MAID. Some had put their memberships on hold, and 35 were willing only to assess for eligibility.
A spokesman for the ministry also pointed out that 72 clinicians joined the old referral list – which was accessible only to physicians and nurse practitioners – in the first month, similar to the sign-up rate for the new service.
Shanaaz Gokool, the chief executive officer of Dying with Dignity Canada, said a doctor in Marathon, near Thunder Bay, has performed telemedicine assessments for MAID in Southern Ontario. "It's a real problem, the shortage in the number of physicians," she said.
In Ontario, 548 people have chosen a medically assisted death since the federal law took effect a little more than a year ago.