MAID for mental disorders: Insight from Dr. Lilian Thorpe
News & Updates | August 25, 2023 | Dying With Dignity Canada
You have been involved in the development of medical assistance in dying (MAID) processes in your province, for the Canadian Association of MAID Assessors and Providers (CAMAP), and as part of Health Canada’s MAID practice standards working group. Do you think the legal criteria and safeguards are adequate, and protect people across Canada from misuse?
Legal criteria provide a framework for clinical practice, but themselves cannot alone deal with the many complexities in a person’s health and care which need to be considered by a responsible health care provider.
As in other areas of medicine, patients are protected by established standards based on good clinical practice, taking into account the individual needs, vulnerabilities and choices of the patient. The Model Practice Standard developed by Health Canada with its companion document called Advice to the Profession provides much necessary guidance to how a responsible, caring and ethical clinician needs to act based on the law. For example, both documents help us navigate the complicated interpretations of incurability and irreversibility with an individual person-centered focus, wherein we explore what available and efficacious treatments have been tried and considered (and if not, why not?).
If well enshrined into practice and amongst the provincial colleges, the new Model Practice Standards along with the legal criteria and safeguards will provide a strong framework within which clinicians can work with safety ensured for patients and their families.
What can you tell people who have concerns about the criteria and safeguards for Canada’s assisted dying law? For example, that there will be a slippery slope and MAID will be available to anyone or that it is an answer to government failings.
Many people do indeed believe that the increasing broadening of criteria represent a slippery slope, whereas others believe that autonomy of patient choices should be the primary principle, with minimal limitations to access. Changes over time have certainly increased rapidly, so many of us would agree that the slope is steep, yet it need not be slippery if there are strong railings, or carefully established parameters to best practice. The considerable and ongoing differences of opinions on this topic still require interactive and respectful dialogue over time in society as experience grows with MAID and the practice parameters are updated.
Many people also worry that MAID will be used in response to government failing to provide appropriate supports and services. However, increased societal visibility of difficult end of life choices has put the lack of medical, psychiatric and social services into the spotlight, and might well be an impetus for overall improvement in care. As an example, since 2016, there has been much more discussion about end-of-life issues, and I am somewhat less likely now to see patients pressured to accept large numbers of treatments that are not beneficial to their quality of life. That being said, we still have a long way to go in improving end-of-life care, and making palliation in outpatient settings, long-term care and palliative care units more accessible. Perhaps the availability of MAID will help us gradually get there.
MAID for mental disorders will become legal in March 2024. What will a MAID assessment for a mental disorder as the sole underlying medical condition (MD-SUMC) look like?
The law says that for patients without reasonably foreseeable natural death (Track II) one of the clinicians involved in a MAID assessment must have expertise in the condition(s) for which the patient has requested MAID, and if that is not the case, appropriate consultation needs to be sought from someone with this expertise.
“A practitioner with expertise in the condition causing the patient’s greatest suffering has been consulted to consider with the patient the reasonable and available means to relieve the patient’s suffering and the patient has given serious consideration to these means. The results of these consultations will be shared with the other assessing practitioners”
MAID assessments for MD-SUMC will likely also involve patients without reasonably foreseeable natural death, therefore Track II, and assessments will need to follow these requirements. The Health Canada guidance document further suggests the following:
“The choice of the person with expertise (or people, if multiple types of expertise are required) should be directly related to the knowledge and experience that is required by the case. Although the person with expertise is not legally required to be a medical specialist, the clinical opinions being sought will often require specialty-level knowledge and experience. For example, in the majority of cases where the requester has a mental disorder as a sole underlying medical condition (MD-SUMC), a psychiatrist or even a psychiatric subspecialist will likely be the person with expertise. However, there may be MD-SUMC requests in which the specifics of the person’s condition mean that the person with expertise should be a geriatrician, a neurologist, or a consultant from addictions medicine.”
Assessments will require a detailed exploration about the disorder, suffering, prognosis, irreversibility and treatments. Assessors will need to explore what treatments have been tried, what has worked, how actively the patient has engaged in those treatments, and whether there are any other reasonable remaining options to reduce the suffering or improve the functioning of the person. The Health Canada Advice to the Profession document states:
“‘Irreversible means there are no reasonable interventions remaining, where reasonable is determined through a process of the clinician and patient together exploring the recognized, available, and potentially effective interventions in light of the patient’s values, overall state of health, beliefs, values, and goals of care.”
“At the time of the MAID eligibility assessment, assessors and providers should explore attempts at interventions made up to that point, outcomes of those interventions, and severity and duration of illness, disease, or disability. How many interventions, how many kinds of interventions, and over what period of time will vary according to the requester’s baseline function as well as functional goals.”
It may take a long time for these detailed assessments for MD-SUMC to be completed because of necessary assessments and trials of available and affective interventions. It is likely that, although more people will apply, only a small number of people will be found eligible and then access MAID, similar to the situation in European countries where this is already legal.
What do you say to people who think mental disorders are different than physical conditions and therefore, should be excluded from MAID?
Physical and mental medical conditions are not independent of each other. Most physical conditions are impacted by a patient’s mental health, including how they cope with or perceive their health. Similarly, most mental health conditions, especially the most serious mental disorders, have very strong biologic underpinnings. Assessments for MD-SUMC will likely be very similar to assessment of patient’s without reasonably foreseeable natural death where assessors are already assessing the impact of considerable mental health and psychosocial comorbidities.
Can you explain some of the potential benefits that could occur from MAID assessments for people with mental disorders?
MAID for primary mental disorders is certainly of great worry to many people because those with mental disorders often have a very negative view of themselves and their potential for improvement. However, it is also possible that the availability of MAID for primary mental disorders may result in some harm reduction. This might occur because patients with significant psychiatric disorders who are in crisis and thinking about ending their life, may be more likely to talk to someone if they think they might achieve a peaceful death. The unintended consequence of talking to a MAID assessor about their distress may then reduce the suffering by the patient knowing that somebody has heard and acknowledged their pain. That conversation might also result in the patient connecting with alternate resources that might decrease their wish to die. Patients with severe medical disorders that have asked for medical assistance in dying often do not proceed with it because they achieve a sense of control. This might also be the case for patients with primary mental disorders.
Lastly, the small number of people who might be found eligible for MAID for sole mental disorders might be able to have a peaceful death with appropriate preparation for family members instead of ending their lives in quiet desperation which so often results in much trauma to those who find them, from first responders to families and friends.
For the average person who has concerns about MAID for mental disorders, what do you say to them?
There are now national, professional guidelines in place that should be able to help us make sensible, rational, caring and well-balanced decisions for people with mental disorders who request MAID. If we continue working on educational strategies to ensure consistent knowledge of appropriate practices throughout the country, (such as through the learning models developed by the Canadian Association of MAID Assessors and Providers with the help of Health Canada) and ensure that our approaches are consistent across the country, MAID for sole mental disorders will become less worrying.