Deadlines, Deferrals and Dialogue: Parliament’s Evolving Approach to Medical Assistance in Dying for Mental Illness

Death with Dignity in Canada

12028 Background: Medical assistance in dying (MAiD) was legalized in Canada in 2016. Cancer accounts for 60-70% of MAiD cases, though little is known about the demographic profile, cancer diagnoses, and treatments received in patients with cancer who pursue MAiD. We reviewed all patients with cancer who underwent MAiD through a large regional MAiD program, in order to better understand this population and identify gaps in the current system of care delivery. Methods: All patients with cancer who received MAiD through the Champlain Regional MAiD Network (CRMN) from June 1 2016 – November 30 2020 were reviewed. The CRMN provides the majority of MAiD services covering a population of 1.3 million in Eastern Ontario. Baseline demographic factors, diagnostic information, and treatment details were collected by retrospective review. The primary endpoint was the proportion of patients with an oncology consultation prior to MAiD. Results: During the study period, 255 patients with cancer underwent MAiD. Baseline characteristics included: median age at death 71 (range 31-100), 51% male, 56% married/common-law. The most prevalent solid tumors were gastrointestinal [GI] (n = 77, 30%), lung (n = 47, 18%), and genitourinary [GU] (n = 35, 14%). Most patients (n = 201, 79%) had metastatic disease at the time of MAiD. Of those without metastatic disease at time of death, common tumor sites included central nervous system (42%) and head and neck (23%). The majority of patients (n = 229, 89%) had seen an oncology specialist prior to MAiD; 226 (88%) had seen a systemic oncologist (medical, hematologic, or gynecologic oncologist), and 189 (69%) a radiation oncologist. Seventy-three percent of patients were followed by a systemic oncologist within 90 days of MAiD, and 44% within 30 days of MAiD. At least one line of systemic therapy was received by 159 (62%) patients, 138 (54%) received radiotherapy, and 61 (24%) best supportive care alone. Median time from last systemic therapy to MAiD was 85 days, and from last radiation therapy to MAiD was 137 days. Palliative care assessed at least 213 patients (84% [8% unknown]). Common reasons for pursuing MAiD included disease-related symptoms (33%), fear of future suffering or disability (19%), and ability to control the time and manner of death (17%). Among 26 patients who had not seen an oncologist, median age was 84 (range 61-100), 77% male, 42% GI primary / 19% GU / 15% lung. Most had seen a palliative care specialist (n = 23, 88%), and in the remaining 3 patients palliative care involvement was unknown. Conclusions: MAiD is a relatively new option for patients with cancer in Canada. The vast majority of patients with cancer who pursue MAiD are diagnosed with advanced/incurable disease, and most have met with an oncology specialist. As cancer treatments become more effective and more tolerable, collaboration between oncologists and MAiD providers is required to ensure patients are well informed of treatment options prior to MAiD.

The first international roundtable on “organ donation after circulatory death by medical assistance in dying” demonstrates increasing incidence of successful patient-driven procedure

Aims and objectivesTo describes nurses' moral experiences with Medical Assistance in Dying in the Canadian context.BackgroundNurses perform important roles in Medical Assistance in Dying in Canada and do so within a unique context in which Medical Assistance in Dying is provided through healthcare services and where accessibility is an important principle. International literature indicates that participating in Medical Assistance in Dying can be deeply impactful for nurses and requires a high degree of moral sense‐making.DesignA qualitative interview study guided by Interpretive Description using the COREQ checklist.ResultsFifty‐nine nurses from across Canada participated in the study. The decision to participate in Medical Assistance in Dying was influenced by family and community, professional experience and nurses' proximity to the act of Medical Assistance in Dying. Nurses described a range of deep and sometimes conflicting emotional reactions provoked by Medical Assistance in Dying. Nurses used a number of moral waypoints to make sense of their decision including patient choice, control and certainty; an understanding that it was not about the nurse; a commitment to staying with patients through suffering; consideration of moral consistency; issues related to the afterlife; and the peace and gratitude demonstrated by patients and families.DiscussionThe depth of nurses' intuitional moral responses and their need to make sense of these responses are consistent with Haidt's theory of moral experience in which individuals use reasoning primarily to explain their moral intuition and in which moral change occurs primarily through compassionate social interaction. Further, work on the moral identity of nursing provides robust explanation of how nurses' moral decisions are contextually and relationally mediated and how they seek to guard patient vulnerability, even at their own emotional cost.ConclusionMedical Assistance in Dying is impactful for nurses, and for some, it requires intensive and ongoing moral sense‐making.Relevance to clinical practiceThere is a need to provide support for nurses' moral deliberation and emotional well‐being in the context of Medical Assistance in Dying care.

The Right to Choose

BackgroundFollowing several landmark rulings and increasing public support for physician-assisted death, in 2016, Canada became one of a handful of countries legalising medical assistance in dying (MAiD) with Bill C-14....

On June 17, 2016, the Canadian government legalized medical assistance in dying (MAID) across the country by giving Royal Assent to Bill C-14. This Act made amendments to the Criminal Code and other Acts relating to MAID, allowing physicians and nurse practitioners to offer clinician-administered and self-administered MAID in conjunction with pharmacists being able to dispense the necessary medications. The eligibility criteria for MAID indicates that the individual 1) must be a recipient of publicly funded health services in Canada, 2) be at least 18 years of age, 3) be capable of health-related decision-making, and 4) has a grievous and irremediable medical condition. Because this is a new practice in Canadian health care, there are no published Canadian statistics on MAID cases to date, and this paper constitutes the first analysis of MAID cases in both the province of Ontario and Canada. Internationally, there are only a few jurisdictions with similar legislation already in place (US, the Netherlands, Belgium, Luxembourg, Switzerland, Columbia, Japan, and the United Kingdom). The published statistics on MAID cases from these jurisdictions were reviewed and used to establish the current global practices and demographics of MAID and will provide useful comparisons for Canada. This analysis will 1) outline the Canadian legislative approach to MAID, 2) provide an understanding of which patient populations in Ontario are using MAID and under what circumstances, and 3) determine if patterns exist between the internationally published MAID patient demographics and the Canadian MAID data. Selected patient demographics of the first 100 MAID cases in Ontario were reviewed and analyzed using anonymized data obtained from the Office of the Chief Coroner for Ontario so that an insight into the provision of MAID in Ontario could be obtained. Demographic factors such as age, sex, the primary medical diagnosis that prompted the request for MAID, the patient rationale for making a MAID request, the place where MAID was administered, the nature of MAID drug regimen used, and the status/specialty of medical personnel who administered the MAID drug regimen were analyzed. The analysis revealed that the majority of the first 100 MAID recipients were older adults (only 5.2% of patients were aged 35-54 years, with no younger adults between ages 18-34 years) who were afflicted with cancer (64%) and had opted for clinician-administered MAID (99%) that had been delivered in either a hospital (38.8%) or private residence (44.9%). Although the cohort was small, these Ontario MAID demographics reflect similar observations as those published internationally, but further analysis of both larger and annual case uptake in both Ontario and Canada will be conducted as the number of cases increases.

Issue: Medical assistance in dying (MAID) became legal in Quebec on December 10, 2015, and in the rest of Canada on June 17, 2016. This enabled 6,749 deaths through physician-assisted suicide or euthanasia between December 10, 2015 and October 31, 2018. While the death of a patient is a common experience for medical trainees, those that occur through MAID have unique features related to the methods, the timeline, the intended role of the physician in causing the death, and the request of the patient that initiates the process. These aspects necessitate a distinct approach to MAID medical education. Evidence: Despite the legalization of MAID in a growing number of jurisdictions, there is virtually no literature to guide MAID education in clinical practice. The cumulative evidence regarding the impact of patient death on medical students, residents, and attending physicians suggests a need for supported discussion and debriefing to process and reflect on the emotional experiences that follow patient death. This is especially important with MAID, in which there are unique ethical and psychological issues related to the physician’s direct role in causing the death of a patient. There is little published research on the impact such deaths have on physicians who provide MAID, or on others who are indirectly involved. However, there is evidence that learners desire MAID-specific education tailored to their unique needs. Didactic education about the medical and legal domains of MAID alone is insufficient to support learners’ needs. Experiential case-based learning with supervisory support has the potential to enhance training in end-of-life care in general, and specifically in MAID. The authors’ first clinical experience with a patient requesting MAID on an internal medicine clinical teaching unit (CTU) highlighted gaps in their preparedness to meet the associated professional and personal demands. Reflecting on these perceived gaps, and on the needs of learners identified in the literature on patient death and MAID education, the authors created a framework to guide learning at the point of care of a patient requesting MAID. Represented in a MAID Education Cogwheel and discussion guide, this framework specifies learning objectives and methods in six domains: medical, legal, moral, ethical, cultural, and psychosocial. Implications: Following a MAID request, attending physicians can use the framework to guide learners in ongoing conversations addressing these domains. Inter-professional participation can include such disciplines as psychiatry, palliative care, bioethics, pharmacy, nursing, physical and occupational therapy, social work, and spiritual care. Further research is necessary to test this framework to determine its’ feasibility, efficacy, and generalizability.

ObjectivesThe aims of this study are: (1) to create a flowchart process model of how medical assistance in dying (MAID) occurs in Nova Scotia (NS), Canada and (2) to detail...

64 Background: With the passage of Bill C-14 in June 2016, medical assistance in dying (MAiD) was formally enacted into Canadian law. Since then, approximately 2,000 patients have died with medical assistance across the country, with cancer being the most common qualifying condition. We aimed to understand the views of oncology providers (OPs) regarding MAiD. Methods: We designed and administered an online survey to Canadian OPs’ to assess experience with MAiD, self-perceived knowledge, willingness to participate, and perception of the role of OPs in introducing MAiD as an end-of-life care option. We used complete sampling via the Canadian Association of Medical Oncologists (CAMO) and the Canadian Association of Radiation Oncologists (CARO) membership email lists. The survey was sent to 366 Radiation Oncologists, and 325 Medical Oncologists. Data was collected from April-June 2018. Results were analyzed using descriptive statistics as well as univariate and multivariate analysis. Results: We received 224 responses (response rate 32.4%). 70% of OPs have been approached by patients requesting MAiD. OPs were confident in their knowledge of the eligibility criteria, and previous exposure to MAiD was associated with confidence in this domain (odds ratio [OR]=3.77, 95% CI=2.05-6.94, p value<0.001). OPs were most willing to engage in MAiD with an assessment for eligibility, yet most refer to specialized teams for assessments. A majority of physicians (52.8%) would initiate a conversation of MAiD with a patient under certain circumstances, most commonly the absence of viable therapeutic options, coupled with unmanageable patient distress. Conclusions: In this first national survey of Canadian OP’s regarding MAiD, we found that most OP’s encounter patient requests for MAiD, are confident in knowledge of eligibility, and are willing to act as assessors of eligibility. Many OP’s believe that it is appropriate to present MAiD as a therapeutic option at the end of life under some circumstances. This finding warrants further deliberation amongst national/regional bodies for the development of consensus guidelines in order to ensure equitable access to MAiD for patients who wish to pursue it.

In June 2016, Bill C-14 or Medical Assistance in Dying legislation became law in Canada. With this law came changes to nurses' (ie, nurse practitioner, registered nurse, registered practical nurse) scopes of practice, roles, and responsibilities. While federal law, regulatory, and organizational policies are developed to inform nurses about the practice of medical assistance in dying, there is little evidence examining how nurses' roles and responsibilities are enacted in practice. Therefore, a scoping review was conducted to synthesize the evidence on nurses' roles and responsibilities in relation to medical assistance in dying and to identify gaps in the literature. A secondary aim was to identify organizational supports for nurses to effectively and ethically engage in medical assistance in dying. Using a recognized and rigorous scoping review methodology, the findings from 24 research studies were synthesized in this article. The analysis highlights the importance of effective health care professional engagement with the individual in the decision-making process and of the need to educate, support, and include nurses in providing medical assistance in dying. Overall, the current research on medical assistance in dying is limited in Canada, and more attention is needed on the role of the nurse.

<p dir="ltr">This is the final report of the research study entitled <i>'At What Cost? Framing Mental Illness in Digital News Media Coverage of Medical Assistance in Dying (MAID)'</i>. This report contributes to the recent and growing body of scholarship on the rapidly shifting terrain of MAiD in Canada. Our study aimed to capture how Canadian news media portrays MAID's impending expansion to include mental illness and frames the lives of people diagnosed with mental illness. Further, it aimed to evaluate the sociopolitical risks of current news reporting practices. Our team conducted a critical discourse analysis (CDA) of English-language Canadian news media articles from 2020 to 2024 (n=367) using Factiva to understand how MAID MD-SUMC and people diagnosed with mental illness are rhetorically represented within these texts. Outlining the evolution of MAID legislation in Canada and ongoing debates on whether or not MAiD should be considered a form of suicide, the contextual groundwork for the project is laid out. Several limitations related to the use of Factiva are acknowledged.</p><p dir="ltr">Our analysis of Canadian news reports underscore how MAiD MD-SUMC is primarily written up as a political news story rather than a health issue. Articles primarily reported on the actions of politicians on Parliament Hill. The voices and everyday experiences of people with lived experience (PWLE) of mental illness were limited. This absence raises concerns about the implications of MAID's expansion for impacted communities.</p><p dir="ltr">Our textual analysis attended to article headlines, who spoke within the text, the words used to describe MAiD and mental illness, and discussions of death. Findings draw attention to the consequences of mainstream news media coverage that consistently pairs 'mental illness' with 'suffering'.</p><p dir="ltr">To enhance the quality and inclusivity of MAID MD-SUMC reporting, four recommendations are made. First, it is recommended that MAID be reported on as a health issue rather than political news, to better engage the public in health matters. Second, it is recommended that Canadian media guidelines for MAiD be developed and that impacted communities be involved in the development of those guidelines. Third, emphasis is placed on the need to minimize harm. Avoid equating mental illness with suffering in reports about MAID MD-SUMC in order to prevent harmful stereotypes. Fourth, it is recommended that news outlets and reporters covering MAID consider the photographs they use more carefully, to avoid tropes.</p>

<p dir="ltr">This is the final report of the research study entitled <i>'At What Cost? Framing Mental Illness in Digital News Media Coverage of Medical Assistance in Dying (MAID)'</i>. This report contributes to the recent and growing body of scholarship on the rapidly shifting terrain of MAiD in Canada. Our study aimed to capture how Canadian news media portrays MAID's impending expansion to include mental illness and frames the lives of people diagnosed with mental illness. Further, it aimed to evaluate the sociopolitical risks of current news reporting practices. Our team conducted a critical discourse analysis (CDA) of English-language Canadian news media articles from 2020 to 2024 (n=367) using Factiva to understand how MAID MD-SUMC and people diagnosed with mental illness are rhetorically represented within these texts. Outlining the evolution of MAID legislation in Canada and ongoing debates on whether or not MAiD should be considered a form of suicide, the contextual groundwork for the project is laid out. Several limitations related to the use of Factiva are acknowledged.</p><p dir="ltr">Our analysis of Canadian news reports underscore how MAiD MD-SUMC is primarily written up as a political news story rather than a health issue. Articles primarily reported on the actions of politicians on Parliament Hill. The voices and everyday experiences of people with lived experience (PWLE) of mental illness were limited. This absence raises concerns about the implications of MAID's expansion for impacted communities.</p><p dir="ltr">Our textual analysis attended to article headlines, who spoke within the text, the words used to describe MAiD and mental illness, and discussions of death. Findings draw attention to the consequences of mainstream news media coverage that consistently pairs 'mental illness' with 'suffering'.</p><p dir="ltr">To enhance the quality and inclusivity of MAID MD-SUMC reporting, four recommendations are made. First, it is recommended that MAID be reported on as a health issue rather than political news, to better engage the public in health matters. Second, it is recommended that Canadian media guidelines for MAiD be developed and that impacted communities be involved in the development of those guidelines. Third, emphasis is placed on the need to minimize harm. Avoid equating mental illness with suffering in reports about MAID MD-SUMC in order to prevent harmful stereotypes. Fourth, it is recommended that news outlets and reporters covering MAID consider the photographs they use more carefully, to avoid tropes.</p>

Bill C-14 allows for medical assistance in dying (MAID) for patients who have intolerable physical or psychological suffering that occurs in the context of a reasonably foreseeable death. In Canada, psychiatrist support for MAID on the basis of mental illness and beliefs influencing level of support are unknown. The objectives of this research were to 1) determine if psychiatrists are supportive of MAID under certain conditions and on the basis of mental illness and 2) determine what factors are related to psychiatrist support for MAID on the basis of mental illness. This cross-sectional study was conducted among 528 psychiatrists in Canada using an online survey platform (February 19 to March 11, 2016). The response rate was 20.9% ( n = 528). Most psychiatrists supported the legalisation of MAID in some circumstances (72%); however, only 29.4% supported MAID on the basis of mental illness. Factors correlating with decreased support for MAID for mental illness were the belief that MAID for mental illness would change the psychiatrists' commitment to their patients through enduring suffering, having a personal faith, and having had past patients who would have received MAID for mental illness were it legal but instead went on to recover. This study found that most psychiatrists do not support the legalisation of MAID for mental illness, despite being quite supportive of MAID in general. Objections seemed to be based upon concern for vulnerable patients, personal moral objections, and concern for the effect it would have on the therapeutic alliance.

Medical assistance in dying (MAiD) was legalized in Canada in 2016. Canadians’ opinions on the service are nuanced, particularly as the legislation changes over time. In this paper, we outline findings from our review of representations of MAiD in Canadian news media texts since its legalization. These stories reflect the concerns, priorities, and experiences of key stakeholders and function pedagogically, shaping public opinion about MAiD. We discuss this review of Canadian news media on MAiD, provide examples of four key themes we identified (vulnerability, autonomy, dignity, and human rights), and discuss their implications for health policy and equity. Though key stakeholders share the values of autonomy, dignity, and human rights, they appeal to them in diverse ways, sometimes with conflicting policy demands. These representations offer a useful gauge of how views about MAiD continue to shift alongside changes in federal legislation. These stories can influence related policies, respond to the powerful voices that shape MAiD legislation, and have the potential to change national conversations. Our analysis adds to the existing body of scholarship on MAiD by examining post-Bill C-7 news media, identifying related health equity issues and tensions, and discussing potential impacts of MAiD’s representations in news media.