Guest blog post: What I've learned about Alberta's approach on assisted dying

It's been two months since assisted dying became decriminalized in Canada, and medical professionals and government officials across the country continue to grapple with what it means to provide safe, fair and consistent access to this new Charter right. In a special guest blog post, former Dying With Dignity Canada board member John Warren takes a look at access to medical assistance in dying (MAID) in the province of Alberta.

I asked my doctor this question recently: “Doc, if I were mentally competent and suffering intolerably from a disease or condition that was killing me, and if my life expectancy was less than, say, six months, would you help me to end my suffering?”

“No, I wouldn’t, but I would refer you to Alberta Health,” the doctor said, before giving me a name at Chinook Regional Hospital (CRH).

From there, a meeting was set up with Dr. Jim Silvius from Calgary, the physician in charge of MAID throughout Alberta Health Services, and two executives from CRH, Dr. Vanessa Maclean and Sean Chilton, who run the MAID program in southern Alberta. The four of us met for an hour and a half and discussed how dying patients can access medical assistance in dying here.

I learned from that meeting that there are four distinct phases to MAID in Alberta: contemplation, determination, action and care after.

Contemplation

The MAID process starts with the patient or family member making an inquiry to the patient’s physician or to an AHS staff member (e.g., nurse in hospital). In Lethbridge, specifically, all inquiries are centralized through the MAID care coordination team.

The most responsible physician (MRP) is the physician or nurse practitioner (NP) dealing directly with the patient. The MRP is asked whether they are willing to be involved with providing information and counselling to the patient. They are also asked if they are willing to assess the patient and if they are prepared to implement MAID.

If the MRP is willing to do all of the above, it will be up to them to provide the patient/family with information and to discuss all of the patient’s options, including palliative care. The MRP must also review the process necessary for the implementation of those options. If the MRP is unwilling to be involved with MAID, they will notify the care coordination team and a member of this team will tell the patient of the MRP’s decision not to be involved. The team will then identify willing physicians and/or NPs for assessments, as well as contact the MAID coordination service and identify any supporting staff necessary (e.g., speech/language pathology, ethics, spiritual).

If the patient makes the decision to proceed, the process moves to the determination stage.

Determination

A physician or NP assesses the patient to determine whether or not they are mentally competent to make a decision regarding MAID. If the patient is mentally competent, they must complete a Record of Request for Medical Assistance in Dying form in the presence of two independent witnesses. If the patient is found not competent, he or she is denied the right to request MAID.

A physician or NP also assesses the patient to determine whether the patient qualifies for MAID under Bill C-14, Canada's new assisted dying law. In order to qualify, the patient must:

  1. have a serious and incurable illness or disability;
  2. be in an advanced state of irreversible decline in capability;
  3. be enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and
  4. the patient’s natural death must be reasonably foreseeable.

A second assessment confirming that the patient meets the conditions specified by Bill C-14 must then be made by another physician or NP acting independently from the first.

If either assessment finds that the patient is not eligible, the patient may request a second opinion, in which case another physician/NP will perform another assessment. Their decision is final.

If the patient is eligible for MAID, the care coordination team identifies a patient team to implement it. The team will consist of the prescribing physician, technical support for the physician (i.e., meds/IV, etc.), a pharmacist and another person to support the patient and the family (e.g., social worker, ethics counsellor, spiritual carer).

The patient is asked to decide whether they would prefer death to occur at home, in a hospital or in another facility, and whether the procedure will be carried out orally or intravenously. The patient will decide who will be present at their death.

Action

The patient team will prepare a plan dealing with the logistics, such as determining the date and time of the death and the care that will be needed for the family, ordering and obtaining the necessary meds and ensuring adequate social and emotional support for the team’s members. AHS staff will ensure that the necessary paperwork and reports are completed. The patient must sign a final form of consent, which must be witnessed.

Before administration of medication all checklists must be completed and the team must confirm that the patient knows he or she can rescind the request. After administration of the medication, AHS staff notifies the medical examiner and arranges for the care and transport of the body to the medical examiner, who performs an examination and transports the body back. 

Care after

Support for both the family and the team’s members is identified and implemented. The MAID Debrief Guidelines are used to gather information and reactions from all team members, and consideration is given to inviting the patient’s family to provide feedback prior to the debrief.

The team shares what’s been learned with the family, as well as with the South Zone MAID planning group, South Zone leadership and provincial MAID leadership. If necessary, improved procedures will be implemented to be followed in the future.

In our discussion, we also talked about the position of patients in the care and control of facilities run by the Catholic healthcare institution, Covenant Health. These include the only palliative care beds in Lethbridge at St. Michael’s Health Centre and the long-term care facilities, St. Therese Villa and Martha’s House. Covenant Health continues to work closely with AHS to ensure the appropriate care options are available to patients within their facilities and who request MAID.

Currently, patients living in a Covenant Health facility who request MAID will be supported outside of the Covenant facility, either in the community or in another facility to ensure their care choices are addressed.

Looking ahead

I am happy that I live in Alberta for many reasons, and I have just found another one. The respect, care and compassion that the MAID team from AHS gives to the patients, families and medical staff seems to be the best possible.

But Albertans must continue to raise their voices in defense of patients’ rights, so that dying individuals across the province aren’t forced to move to another facility, or even to another region, in order to realize their wish to die in peace and with dignity. While physicians and staff have a perfect right to decide not to be involved with MAID, institutions involved in the care of patients must not be allowed to withhold legal medical procedures from them.

John Warren is a member of Dying With Dignity Canada’s Lethbridge chapter and a former vice president of the organization’s national Board of Directors.

(Header credit: abdallahh/Flickr)


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