It can be a touchy subject to discuss, but it’s one we must broach if we are to work toward fair access to assisted dying across Canada.
What physicians are paid to assess for and provide medical assistance in dying (MAID) is emerging as a possible barrier to access across the country. According to a new report written by The Globe and Mail’s Kelly Grant, a number of doctors in British Columbia are dropping out of providing assisted dying because the pay they receive is unsustainably low. In Nova Scotia, most of the province’s assisted dying providers have not been paid for their MAID-related work.
Inadequate compensation for MAID providers is unfair, and not just for the physicians. We at Dying With Dignity Canada (DWDC) are concerned, first and foremost, about the impact that this phenomenon will have on suffering Canadians — those who wish to access their right to a peaceful death. Unless there are enough doctors who feel comfortable participating in MAID, Canadians, especially those in rural and remote communities, will continue to face difficulties in finding providers.
Below is a backgrounder we produced in conjunction with the Canadian Association of MAID Assessors and Providers on how inadequate compensation for assisted dying affects access for Canadians. Although the details of the fee rates in this case are specific to B.C., the take-home message is applicable across the country.
In British Columbia, the current fees for clinicians who assess and provide medical assistance in dying (MAID) are woefully inadequate given the amount of time, legal responsibility, emotional burden and complexity of care required in this area of practice. On Vancouver Island, the withdrawal of previously active assessors and providers has already put additional pressure on the remaining MAID clinicians. And unless the Medical Services Committee allows full and fair compensation for MAID, there is a grave risk that more clinicians across B.C. will withdraw from assessing for and providing this important service.
Impacts on vulnerable British Columbians
If there are fewer clinicians assessing for and providing MAID, desperate British Columbians will face additional harmful barriers to access. Potential impacts on vulnerable patients include, but are not limited to:
- Longer wait times to see a clinician. This is not only excruciating for patients who are already suffering intolerably, but it could also lead to a patient losing capacity before they are able to access their constitutional right to a dignified death.
- Poorer access in remote and rural regions. Inadequate fees make it difficult for providers and assessors to travel to rural and remote communities where there are no local clinicians who are willing to provide MAID.
- Poorer access to MAID in the home. Most MAID patients in B.C. choose to die at home. More may have to go to the hospital in order to have access unless providers are compensated for their in‐community travel time.
Fees for MAID must reflect the nature of the work
The fee structure imposed by B.C.’s Medical Services Committee allows the primary provider in a MAID case to bill $40 per 15 minutes for an assessment, up to a maximum of 90 minutes. (The second assessor may only bill for up to 75 minutes.) This is despite the fact that a straightforward MAID assessment takes upwards of three hours. A flat fee of $200 has been implemented for the actual provision of MAID. A home‐visit or hospital‐visit fee may also apply, depending on where the medically assisted death is to take place.
If these fees take hold, clinicians would earn about half as much for their MAID‐related work as they would if they were to spend the same amount of time providing routine office‐based care. Specialist physicians would earn about 30 per cent as much as they would normally bill for the same amount of time. These rates do not offer any compensation for travel time and expenses, which can be extensive in some cases.
Not only is the current fee structure unfair to clinicians, but more importantly, it sends a troubling message to British Columbians who may in the future ask to be assessed for MAID. It communicates that physicians and nurse practitioners should spend no more than 75 or 90 minutes considering an individual’s request for MAID — regardless of the complexity of the particular case, the volume of the patient’s relevant medical records, or the number of questions the patient has about MAID or their other end‐of‐life treatment options. We reject the notion that clinicians should provide anything but a robust and well‐considered assessment for MAID; conversely, this care must be delivered with the attention and compassion that British Columbians expect and deserve. After all, for the patient, this is the most consequential decision of their life.
Any fees proposed for MAID must reflect this reality.
Steps that must be taken immediately
- The MSC has studied the issue for the past 12 months, but has failed to consult extensively with current MAID assessors and providers. CAMAP and DWDC call for immediate consultations with B.C. medical practitioners who assess for and provide MAID in a number of clinical settings (i.e. in homes, long‐term care residences, hospices and hospitals), to gain a better understanding of the nature of their work.
- Fees for MAID assessments and the administration of MAID must immediately be set at $40.00 per 15 minutes, with no caps. These rates would closely resemble those that have been put in place in other Canadian jurisdictions, and they would allow B.C. clinicians to continue their MAID work while further changes are being considered.
What is involved in assessing for and providing MAID
Medical assistance in dying is complex, challenging and contentious work within the context of the Canadian healthcare system. As a result, MAID assessors and providers number only in the low dozens for the entire province of B.C. At the moment, the majority of clinicians who assess a patient’s eligibility for MAID and provide assistance in dying are not the patient’s family physician.
Assessment is a lengthy process that, in straightforward cases, takes three hours to complete, but can often take longer. Assessments involve, but are not limited to, the following activities:
- Gathering and reviewing the patient’s complete medical records, which often need to be compiled from multiple sources;
- Interviewing the patient to understand their wishes and rationale. This routinely takes 60 to 90 minutes for the initial visit, with subsequent follow‐ups as required;
- Discussions with the family physician as well as multiple specialists, where warranted, to clarify the patient’s medical circumstances and to provide further insight into their eligibility for MAID;
- Discussions with family and/or other supporters as requested by the patient, sometimes outside of initial interview, to clarify information gathered above and inform of the process underway;
- Documenting these activities to the level of detail required by the College of Physicians and Surgeons of B.C.; and
- Filling out provincial MAID forms.
The actual provision of MAID takes, on average, three‐and‐a‐half hours to complete in straightforward cases that are within a 30‐minute drive of the practitioner’s office. Of course, this can take longer. The actual provision of MAID involves, but is not limited to, the following:
- The completion of a six‐page document to be faxed to the pharmacist for the MAID prescription, and a submission to Special Authority for MAID drugs through Pharmacare;
- Travel to the pharmacy to pick up the medication and review patient eligibility with the pharmacist;
- If in community (as the majority of cases are in B.C.), travel to the patient’s home. In many instances, travel time may be extensive for the clinician;Final review of the patient’s capacity to consent to MAID and obtaining written consent from the patient;
- Arranging or directly administering intravenous access;
- Preparation of family and friends for the procedure by: reviewing what the event will entail, answering questions, participating in/facilitating or standing by during any ceremony organized by family and friends;
- Drawing up the drugs (four medications plus up to six saline‐filled syringes);
- Injecting the patient, monitoring the patient and pronouncing death;The College of Physicians and Surgeons of B.C. requires that the clinician be in attendance until the time of death and pronouncement of death. When oral meds are requested, the time of death may be up to two hours after medications were taken;
- Preparing the body for funeral home collection and waiting for funeral home personnel to arrive;
- Completion of forms to go with the body;Travel back to the pharmacy after the procedure to return unused medications to the pharmacy and sign off on paperwork with pharmacist;
- Completion of all provincial forms and faxing the 17 pages of documentation to both the coroner’s office and the regional health authority; and
- Documenting these activities to the level of detail required by the College of Physicians and Surgeons of B.C.