End in Mind: MAID and mental disorders

Jocelyn Downie, PhD. Her work on end-of-life law and policy includes: Special Advisor to the Canadian Senate Committee on Euthanasia and Assisted Suicide; author of “Dying Justice: A Case for the Decriminalizing Euthanasia and Assisted Suicide in Canada”; and more.

Dr. Justine Dembo has been a MAID assessor since 2015 and has been involved in research and teaching on the topic of MAID since 2009.

And now I am thrilled to welcome and introduce today’s speakers. First joining us is Jocelyn Downey. Jocelyn Downey is a university research professor in the faculties of law and medicine at Dalhousie University. Her work on end of life law and policy includes special advisor to the Canadian Senate Committee on euthanasia and assisted suicide, author of Dying Justice: A Case for Decriminalizing Euthanasia and. Assisted Suicide in Canada, and a member of the Royal Society of Canada Expert Panel on end of life decision making, and also the plaintiff’s legal team in Carter versus Canada, the provincial territorial expert advisory group on physician-assisted dying, and the Canadian Council of Academy’s expert panel on Medical Assistance in Dying. She was named a member of the Order of Canada in part in recognition of her work advocating for high quality end of life care. She is also a fellow of both the Royal Society of Canada and Canadian Academy of Health Sciences. So welcome so much Jocelyn for joining us.

Also joining us today is Dr. Justine Dembo. Justine Dembo is a psychiatrist at University Health Network and at Sunnybrook Hospital in Toronto where she specializes in OCD and related disorders and an assistant professor at the University of Toronto. She has been a MAiD assessor since 2015 and has been involved in research and teaching on the topic of MAiD since 2009. She was a member of the government expert panel on MAiD and mental illness and was an expert witness in both the Trauscht and Lamb court cases. She’s an active member of the Canadian Association of MAiD Assessors and Providers through which she’s currently working to produce educational modules on the subject. And she’s also a member of the Canadian Psychiatric Association MAiD Working Group.

So quite the resumes from both of you. We are so happy and grateful to have you join us for this topic. So thank you so much and I’m going to pass it over to Kelsey to get us started.

Hi. Thank you both for being with us today and to our incredible engaged audience who already have lots of questions for you both. So I think we’ll dive right in and get started with some of the topics that we have on deck for today. So to begin, let’s start by getting clear on what the law is in respect to MAiD and mental disorders. So Jocelyn, can you get us started with telling us when, if ever, MAiD for mental disorders will be legal in Canada?

Sure. So to answer this question, I actually have to explain eligibility for MAiD in general and then I can relate it specifically to mental disorders just so everybody’s on the same page to start. So to be eligible for MAiD in Canada, you have to be eligible for government funded healthcare, be 18 years of age or older, have the capacity for making decisions with respect to your health. You have to have made a voluntary choice to request MAiD and it must be free from any kind of external pressure or undue influence from others. You have to give informed consent to MAiD after having been told of all of the alternatives to MAiD and told about MAiD, and you must have been told about palliative care.

You have to then also have a grievous and irremediable medical condition. It’s a mouthful, but it’s defined in the criminal code so we know what it is supposed to mean. It’s supposed to mean that you have a serious and incurable illness, disease, or disability. You have to be in an advanced state of irreversible decline in capability, and you have to be experiencing enduring an intolerable suffering that can’t be relieved by means acceptable to you. And that suffering has to be being caused by either the serious and incurable illness, disease, or disability, or the advanced state of irreversible decline in capability. So generally that’s what you have to have in order to be eligible for me.

Now, right now mental illness is excluded from illness, disease, or disability. So remember a moment ago I said you have to have a serious and incurable illness, disease, or disability. The law says, “By the way, mental illness is not an illness, disease, or disability.” So right away you know that somebody who has a mental disorder as their sole underlying condition cannot be eligible for MAiD because they’re excluded by that provision. But somebody who has a physical illness, disease, or disability, a serious and incurable physical condition and a mental disorder, they can be eligible. So some people with mental disorders, as long as you got another condition, a physical condition and you meet all the eligibility criteria, you can be eligible for MAiD. But if mental disorder is your sole underlying condition, you’re not eligible for MAiD right now. We’ll talk about the future in a little bit, but that’s where we are right now.

Thanks Jocelyn for that background. That’s super helpful. So what does this look like in a clinical context? Jocelyn just gave a overview of what’s legal and what’s not. But what we are hearing is that those with a concurrent mental disorder, that is people applying for MAiD who also have a mental illness, may qualify for MAiD currently and that MAiD assessors do have that experience assessing patients with concurrent mental disorders. So turning to you Justine, can you explain more about this and the types of situations where a person with a mental disorder may receive MAiD under the law that we have in place currently?

Yes, thanks Kelsey. Jocelyn already explained from the legal standpoint some of what we actually would see clinically. And so someone in this category might be a person who has both cancer and depression or they have both multiple sclerosis and PTSD or OCD, obsessive compulsive disorder. So it can be a combination of the physical condition and they also have a mental illness. I definitely want to emphasize that many people requesting MAiD, whether it’s Track One where there is a reasonably foreseeable natural death, or Track Two where there’s not, will also have some kind of mental illness because mental health conditions are quite common. So already that exists on both Track One and Track Two. And Jocelyn’s correct, if the sole reason for the request is a mental illness, someone wouldn’t qualify.

One of the challenges and one of the murky areas here is where there’s someone with both a physical illness and a mental illness whose main reason for the request for MAiD is the mental illness even though they have a qualifying physical condition. That can get really challenging because technically as the law is written, within the requirement for a grievous and irremediable illness, disease, or disability, it’s required that it’s either the illness, disease, or disability or the advanced state of irreversible decline in capability that can qualify as acceptable causes of unbearable suffering. So someone’s advanced decline may actually be more related to their mental illness than to their physical illness even if they have a qualifying physical illness. That’s the letter of the law. In practice, assessors are extremely cautious in these cases where someone’s main reason for the request is a mental illness. We have been veering on the side of caution saying we’re looking at the physical illness must be the main reason for the request or the main driving factor. But it’s a little different in practice from what’s actually written into the letter of the law.

Thanks, Justine. So the next question, you alluded to this a moment ago, Jocelyn. We have the law on MAiD for mental disorders as the sole underlying medical condition and that law was supposed to change this month in March, but now it’s looking likely that that change will happen a year from now. Can you explain, Jocelyn, what’s going on with that aspect of the legislation?

Yeah, so that provision that I mentioned, that a mental illness doesn’t count as a serious illness, disease, or disability in the eligibility criteria, that’s in the law. But then what’s also in the law is what’s called the sunset clause, which is the clause that said that exclusion will be lifted automatically two years after the passage of the law, which is March 17th. Like what? 10 days from now, something like that. So we were set for that to be lifted. So what we call MAiD MD-SUMC, sole underlying medical condition, was to be legal as of March 17th of this year. What’s happened is the federal government decided to seek a delay in coming into effect of the sunsetting and so they passed a bill in the House. It’s in front of the Senate literally this afternoon. It’s had third reading in the Senate and it’s absolutely expected to pass. And so what that would do is it would push out the effect of the sunset clause for one year. And so next March MAiD MD-SUMC, sole underlying medical condition, will become legal because the exclusion will be gone.

Thanks for that Jocelyn. And on that note, in your opinion, why do you think lawmakers originally decided that they would sunset the exclusion of MAiD MD-SUMC?

Yeah, that’s a really important question because when the bill was first introduced it didn’t have a sunset clause, it just excluded mental illness. And when it went over to the Senate, the Senate introduced the sunset clause. The reason for that is they recognized that it couldn’t be excluded forever because that would be a breach of the Canadian Charter of Rights and Freedoms. It would be discrimination on the basis of mental disorder because the only people you’re excluding are people with a mental disorder and you don’t have a justification for it. And so under the charter, you wouldn’t be allowed to do that. So I think that they recognized that a delay was justified to give time to regulators and clinicians to develop the standards and the practices and the guidance in order to know how to do MAiD MD-SUMC well. So a delay would arguably not violate the charter, a full-on ban would.

So they put in the sunset clause to ensure that the ban would be lifted so that they wouldn’t be sort of immediately subject to yet another charter challenge in court arguing that the legislation was unconstitutional. And they knew they couldn’t do it for a couple of reasons. One is just if you do a charter analysis, I think it’s very clear that to have a ban just on mental disorders is a breach of the equality provisions. But we also have a little more than that, which is that we have the Supreme Court of Canada decision in the Carter case, which is the case that gave us MAiD in Canada, and it did not exclude people with mental disorders. We then had a court of appeal decision, the EF decision out of the Alberta Court of Appeal, that was a case of a person with mental disorders, their sole underlying condition, and they gave a constitutional exemption to this woman to enable her to have MAiD under Carter. So they were saying that effectively Carter doesn’t exclude people with mental disorders as sole underlying condition.

And then we also have the Trauscht decision, which looked at this issue and looked at the question of what did the Supreme Court think about mental disorders and the Trauscht decision out of Quebec also said, “No, Carter did not exclude people with mental disorders.” So we have the charters sitting there on its own and we also have these decisions which told parliament, I think, “You can’t do a permanent ban. You can do a delay, but you can’t do a permanent ban.”

I also think they were very concerned, rightly concerned, that a ban would be stigmatizing on persons with mental disorders because it seems to suggest that the suffering that’s caused by physical disorder is somehow sufficient and to justify have allowing assisted dying, but the suffering from a mental disorder isn’t as egregious, it isn’t as excruciating. Or it also seems to suggest maybe people with physical disorders, they have decision making capacity, but we’re not so sure about people with mental disorders, that we have to protect them from making bad decisions. That’s so stigmatizing and it runs counter to what we as a society have been trying to do for decades, which is to acknowledge that the suffering that can come from mental illness is as excruciating as from physical disorders, and also that people with mental disorders absolutely have decision making capacity. Some don’t, just as some people with physical disorders don’t have decision making capacity. But you should not be saying a group of people, or suggesting a group of people lack decision making capacity.

And so we’ve been fighting for that for years. To have an exclusion that is stigmatizing in that way that reanimates those misguided beliefs and attitudes would be really problematic. I think that was in the minds of parliamentarians too when they said, “No, we’re going to have a sunset clause for this. We’re going to allow that temporary exclusion so everybody can get ready, but this is not going to be permanent. We won’t be a part of discriminating and stigmatizing.”

Thanks, Jocelyn. I think those points are so important to raise and it’s also interesting to reflect back on some of these court cases that have already happened and what played out in those situations. So now that we understand the legislative piece and what’s going on currently and what to expect in a year’s time, let’s now explore what this might look like in practice. So there’s been work being done to figure out how MAiD for those whose sole underlying condition is a mental disorder might happen. There’s an expert panel in MAiD and mental illness that you were a part of, Justine. Can you share with us more about the work of that committee and some of the key recommendations that the panel developed?

Sure. Yes. So the government expert panel was tasked with creating potentially safeguards, guidelines, and protocols. The reason those three words are important is that a definition of a safeguard would be something that goes into the criminal code that is required across the country, whereas guidance and protocol would be enacted more on a provincial and local level. So we were tasked with looking at whether all three or some of those three should be introduced. We were a multidisciplinary panel, we had members who were psychiatrists, bioethicists, family doctors, people with lived experience of mental illness. And I may be missing someone there, actually. No, I think that’s about it. Legal scholars as well. That provided a great deal of richness in terms of the ideas we could discuss together and the depth of discussions we can get into, the intensity of analysis of all the information out there.

In addition to our own expertise, we consulted with other individuals or groups who were relevant and we received input that was unsolicited, we also took into account. Ultimately, the panel created 19 recommendations. None of them ended up being safeguards. They all ended up being protocols and guidance. This was because we felt that the current safeguards under Track Two were already quite comprehensive and it would be best for us to enhance the definitions as they might apply specifically to people with sole mental illness rather than create a set of new safeguards.

Also, of those 19 recommendations, I’ll give you a sense of some of the ones that I think are most important, but before that I want to mention that one of the overarching principles we came up with in discussing all of this was that the concerns we were asked to address don’t only apply to sole mental illness. The concerns we were asked to address really could apply across all of MAiD and certainly Track Two where there isn’t a reasonably foreseeable natural death. So we’ve actually recommended that these same protocols and guidance items be applied to Track Two in addition to sole mental illness so as not to exceptionalize or discriminate against people with mental illness.

So of the most important recommendations, some of them had to do with how we establish incurability and irreversibility with respect to the number of prior treatment attempts. Under Track Two, as you heard Jocelyn say, people need to have undergone as many treatments as they find acceptable to themselves. It’s different in the recommendations of the government panel in that in some cases it’s very difficult to establish whether someone has an incurable form of the illness or an irreversible illness without having already tried extensive treatment attempts. So we did recommend that that be done and that be part of what’s required in the assessment.

We also required that there’d be a shared understanding between the person and the MAiD assessors or providers that there is a grievance and irremediable illness and an advanced state of decline in capability and enduring and intolerable suffering. The idea of a shared understanding comes from the Benelux countries such as be Belgium and the Netherlands, where especially in Belgium, that is one of the ways the laws are applied.

We also state that capacity assessments should be very comprehensive. So under the current Canadian law, there is not a specific requirement that capacity assessments be any different for more highly consequential decisions than for less consequential decisions. But in practice, they are different. And in the recommendations by those who develop the gold standard capacity assessment tool, it was recommended that the degree of rigor on the part of the assessor and the degree of abilities possessed by the requester be greater when the decision is more highly consequential or more complex. So we did recommend that approach.

The current safeguard for Track Two, one of the current safeguards is that patients should have been informed of all reasonable means to relieve their endurable suffering and that includes things like counseling or disability supports. We requested that in addition to that, it should include housing and income supports as means available to alleviate suffering. The request for MAiD has to be very well considered, non-ambivalent, and enduring over time. We also said that at least one assessor should be a psychiatrist who’s independent of the patient’s treatment team and that is the person with expertise in condition, which is also required of Track Two already, that someone with expertise in the condition should be consulted. But we went one step further to say that this should actually be one of the assessors and they should be a psychiatrist.

We also recommended that assessors take into account the input of people who know the patient well, and that includes their healthcare providers and their loved ones whenever possible. It’s not always possible, but whenever possible. And that assessors and providers need to be self-reflective, that we need to practice stepping back and asking ourselves what our reactions are to the person in front of us and whether there are any biases or undue influences that we have that may impact the way we assess that person.

One other thing I would say is that there is a requirement for standardized training for assessors and providers and that training modules be developed and that’s what I’m involved with right now with the Canadian Association of MAID Assessors and Providers so that assessors and providers have a more standardized approach and feel more confident.

I think there’s one other that I think is relevant here, which is just the idea of prospective oversight where we recommended that someone take a look at the assessors and providers notes, talk with them potentially ahead of the person being approved just to ensure that they haven’t missed any important aspects of the assessment and that everything has been done the way it is supposed to be done before someone is approved and move through with MAiD. Those are the highlights I would say.

Thanks Justine. Thank you for that overview. That’s a really helpful background as we move through the discussion. Thanks for all your work on the panel. I’m sure it was a lot, a big undertaking and it’s very interesting to read through that report. So thanks for that.

It was well worth it Kelsey. Really well worth it. Thank you.

Great. So Jocelyn, I understand you were part of a task group that was mandated to take one of the key recommendations from the expert panel that Justine just talked about and you were asked to develop a practice standard that the regulators of physicians and nurse practitioners across the country could use to regulate the practice of MAiD for mental disorders. Could you tell us where that work stands now?

Yeah, I’m actually really happy and relieved to say that we’re almost done. So what we did was we took the expert panel report. As you said, we were tasked with operationalizing the major recommendation that was to get practice standards across the country to give support to the development of practice standards across the country. We took that to mean we that we would develop a moral practice standard and advice to the profession because those are the two kinds of documents that the regulators across the country can use. I might have a quick tangent here just to make sure everybody’s sort of up to speed with respect to how these pieces fit together, the criminal code and the regulators, because they’re may be thinking, “Why didn’t you just put it in the criminal code?” as Justine was talking.

So the MAiD law in Canada is established through the federal criminal code. There’s generally a prohibition on assisted dying. And then within the criminal code, you lay out a framework which says “Except where X, Y, and Z is met.” So that’s the core legal framework for MAiD in Canada. But criminal law is federal, the administration of the healthcare system is provincial, healthcare delivery is provincial. Clinicians, nurse practitioners, and physicians are the most relevant here as well as pharmacists, they are self-regulatory bodies. Yeah, they’re regulated by colleges physicians and colleges of nurses and that’s how the conduct is regulated. And so you have this important relationship which is the criminal code sets out the bear framework. And then practice standards give more guidance to clinicians as to how they should practice medicine or nursing. They also are situated in a broader context than the criminal code. So for instance, they have content on conscientious objection, which the federal criminal code cannot do because the federal government has no power over the regulation of healthcare providers. But in a practice standard you could have something about conscientious objection for instance.

So we were tasked with operationalizing expert panel into a model practice standard. We drafted the first version directly in relation to the expert report where we were making it fit with a regulatory standard. So there’s certain language that you use, there’s certain structures that you use, there’s a regulatory context within which a standard like that sits with other regulatory standards that interact with it. So we did that and we sent it out for review to all of the regulators, all of the provinces and territories, the MAiD programs, MAiD assessors and providers and got a lot of feedback, which was wonderful. We then revised it. It’s important to note that it doesn’t then have to map directly onto the expert panel report because it’s being revised in light of it being a regulatory standard, which the expert panel was not. And so it’s responding to the language, the context, the other standards with which it must interact and so on.

So we revised it and it has gone out for translation. It just landed in my inbox for final review. And so it is going to be published and available this month, early next month for a broad public. And then what happens is all the colleges across the country can take that model practice standard and they can then look at their own standard and they can say, “Either we want to adapt this for ourselves or we want to adopt parts of it for ourselves,” but the idea is we will have as much harmonization across the country as we can with respect to the provisions that are in the model practice standard.

And I want to note here just to end on the answer to this question, tying back to something Justine said, which is that this model practice standard is not limited to MAiD MD-SUMC or even to MAiD for mental disorders because so much of what we need to regulate in the context of major mental disorders applies to some physical disorders as well. And so it is a model practice standard for MAiD, not MAiD for mental illness, but within it you will find content and direction and guidance on all of the issues that are of such concern these days with respect to the introduction of MAiD for mental disorders as a sole underlying condition. So it’s almost here.

Thanks, Jocelyn. Good to know. I appreciate, and I’m sure our audience does too, have the different healthcare pieces all work together. So I think that system, unless you’re in it, can get very complicated very quickly, so that information is great as well. So Jocelyn too, there’s some training that’s going to be developed. Can you describe what is going on in that space?

Yeah, so the federal government has funded an extraordinary national initiative. It’s a national curriculum. I’m not aware of ever having done that before because again, you have this division of powers, the federal government does criminal, provinces and territories do health so you wouldn’t normally see that kind of thing. But it’s a wonderful response to the expert panels request for harmonization across the country. How can we get people talking to each other and learning from each other and working in very similar ways across the country without having actually the power to impose that from Ottawa? And so they have funded the development of a national curriculum.

CAMAP, the Canadian Association of MAiD Assessors and Providers, is developing this national curriculum. There’s a big team, lots of expertise from different areas, very national. It is covering all of the issues that you would expect to see or hope to see in a curriculum that is designed to bring people up to speed who want to be MAiD assessors and providers or want a deeper dive on some issues. Maybe they’ve been doing it on some of the simpler cases and now they want to get into some of the more complex cases. And so they will have the ability to watch an asynchronous module and then there will also be synchronous training going along with it for most of the modules, not all of the modules.

So I would flag that MAiD for mental disorders has its own module so people will be able to get that kind of training with a recognition again that mental disorders are not unique, but some of the things that are covered in that module are relevant for physical disorders as well, but people are looking for something that is targeted and so they will find that. The training program is going to be accredited, which is also extremely important. It will be rolling out in the coming months. It’s going to be fully available to anybody, any clinicians, physicians and nurse practitioners, who wish to take it by the fall.

The other thing I’d flag for you is that there’s a training workshop which is going to be held in Montreal in June, which is going to bring together experienced MAiD assessors and providers and psychiatrists. And of course people should know, there is some overlap in that there are a number of psychiatrists who are already MAiD assessors and providers. But bringing together those groups so that they’ll be ready to go when these cases start happening in March of next year, the MAiD sole underlying medical condition. Also so that we are training more people to do work with patients who are coming through with what we call the concurrent conditions, and so they may have a physical and a mental disorder.

So it’s going to be training in respect of how do you deal with MAiD requests when the person is coming through with a mental disorder, whether it’s their sole or not sole. How do you deal with that as a MAiD assessor provider? How do you as a psychiatrist, if you’re not going to be an assessor provider, how do you play the role of the person with expertise Justine referred to? Because if neither the assessor provider have expertise in the condition causing the person suffering, you have an obligation to consult with someone with that expertise. In the case of people with mental disorders, it is most likely but not always going to be a psychiatrist. We want to be sure that psychiatrists of the country are trained and ready to play that role. And then the idea is you have somebody from every jurisdiction and they go through the training and then they go back out and then they’re able to train in their jurisdictions. So that is going to happen in June, which means again, we’re going to be well-prepared for when this all happens next March.

I think it’s also important, I just want to mention it, that’s how training happens. That’s how clinicians come to understand how to do new things. I mean it’s glorious it’s through a national curriculum, you don’t usually have that. But what you often have is these kinds of trainings, and it happens. People put on a workshop. You go and you shadow someone and you do it in medical school or in nursing school, that kind of thing. So people have to recognize this fits into a very well established regime of education, clinical education. We’re in good shape with respect to, I think, the training that is necessary to move forward with MAiD for mental disorders.

Thanks, Jocelyn. It’s clear that both of you have been working so hard on this along with your colleagues. We appreciate hearing more about how that’s been rolling out and what to expect in the coming months. So with a bit of the background pieces covered, based on the work to date and the recommendations and the work and the considerations that have been happening in the space, Justine, can you describe what a qualifying patient under MAiD, sole condition mental disorder, might look like and how eligibility for that patient might be determined once the law does change?

Yes. So I think the best way to do this would be for me to provide a very anonymized example of the kinds of requests I have already received for people who would like MAiD for this reason but are not yet eligible as well as taking into account the hope that what we’ve recommended in the government expert panel and what’s now being created with respect to practice standards is going to be how it’s going to be implemented. So I’m projecting that that’s what it will look like.

So an example of someone who might be eligible under that law, maybe someone who is, let’s say in their 60s, they’ve suffered from a severe mental illness such as depression throughout their lives, maybe since their 20s, for many decades. They have had access to and undergone extensive interventions of different varieties. So there may be treatments that are biological. Let’s imagine someone who’s had 15 or 20 antidepressant trials including maybe mood stabilizers or antipsychotics, which we also sometimes use. They’ve also had maybe neurostimulation, and that would be treatments like electroconvulsive therapy, ECT, or transcranial magnetic stimulation. They would also have had psychotherapy. The standard evidence-based psychotherapy for depression would be cognitive behavioral therapy. We also sometimes use something called interpersonal therapy. They may have undergone individual and group therapy. The person may have also been in hospital before because of exacerbations of their illness and has had hospital or residential treatment.

So it’s someone who has had an extensive history of treatment but without a response in their illness or without sufficient response that their quality of life is acceptable to them, they’re still suffering unbearably. That person would have to meet all the criteria already required, including capacity with respect to decisions and all of the safeguards Jocelyn outlined in the beginning. And that person would be making the request voluntarily, which is part of those requirements. In a perfect world, they would’ve had access to all of the reasonable interventions. And if they hadn’t, they would’ve been helped to get access to that by the MAiD assessor advocating or working with their treatment team to ensure that that’s been done. And this person has hopefully also had access to appropriate income supports and housing. And again, that would be offered if it had not yet been as part of the MAiD assessment.

So this might be the picture of someone you see and I have assessed patients like this, many of whom actually have had the means outside of public healthcare. They actually had the means to achieve numerous treatments and high quality care. And so for those individuals, they’ve reached a point where they can’t bear to continue going on as is still as part of that assessment. I’ll get into some more details of assessment process later if you’d like, but as part of that assessment, we would cover as much ground as possible and look to see are there any stones that have been left unturned that that person might want to pursue. They wouldn’t be forced to, but they might want to.

The second part of your question was looking at how we would actually conduct these assessments, what the process looks like. I could spend hours just on that, so I’m going to try to be concise. I’ll just say that partly the assessment will look like a thorough psychiatric assessment, which includes getting demographic information about the patient, asking them about the reasons for their request, asking them about current symptoms of their mental health condition, also asking about treatment history and psychiatric history, medical history, substance use, their personal life and developmental and family history. And then we would also be assessing the specific MAiD request and looking at their decision making capacity for the MAiD request in particular.

Decision making capacity is a large topic, but there are four main branches of capacity that we typically use and they fit under the umbrella of the two branches of capacity that most provinces require. So the two that the provinces tend to require are that the person has a full understanding of the medical facts relevant to their condition, relevant to treatment options, relevant to the difference between certain treatments or what it might be like to not undergo treatment, so they’ve got the practical information. They also have the relevant medical information about MAiD and how MAiD is performed and what the MAiD assessment requires. And they need to be aware that MAiD would result in death and that death is irreversible.

Then they would need to be able to understand the decision as it applies to themselves in their own context. This relates to their insight about their conditions, about the way that the mental illness could be impacting their decision making capacity if it is, and about how this decision might affect the important people in their lives as well as them. The other two elements of capacity fall into those two categories. They include the ability to make a choice and the ability to reason. The ability to reason is about logical processing of information. It’s not about whether the assessor agrees with the decision, but it’s about can the person manipulate information in a rational and logical way. So we look at all of those four branches of capacity as part of the assessment.

These assessments will not be in one visit. In my experience, assessments on Track Two are often over many visits. Often over many months, even years. The average amount of time I believe in Belgium for assessments for sole mental illness is 10 months, but some are years. And so this is longitudinal. This is a chance to see someone in many different situations over time and get a very full understanding of how consistent their request is and of themselves as a person in the way they’re making this decision. So these are complex assessments.

The assessment process would also involve getting collateral information, as I said, were possible from the treatment team and from loved ones. If there are supports that haven’t been put in place, the assessor’s role would be to speak with a person’s treatment provider about trying to put those in place. And in some provinces, it will be permissible for the assessor to advocate on the behalf of the patient or to make referrals themselves. So I think I’ll stop there. Those are the nuts and bolts of those assessments. And if people have more questions, they can always ask.

Great, thank you Justine. So can we talk a little bit about some of the clinical concerns that have been raised about MAiD for mental disorders? So specifically, people have said that you can’t say that a person’s mental disorder is irremediable or incurable, that their decline is irreversible, that their suffering can’t be relieved. What do you say to those clinical concerns?

Yeah, those are very important concerns that have been raised and it’s created an enormous amount of controversy here, so I’m glad you’re asking about that. There is no way to pretend that there’s an easy 100% clear cut answer in a lot of these cases. I think one of the important principles to keep in mind with respect to the Canadian law is that already under the Canadian law, people make very highly consequential medical decisions that could result in life or death in situations of uncertainty all the time. There’s always uncertainty.

And so this is no different in that sense that although we have population data that can indicate the prognosis for a mental illness in general, we don’t have data for that one individual person in terms of what’s going to happen in that person’s future. We don’t have a crystal ball that can tell us that that person is 100% irremediable. So that person is making a decision in the context of uncertainty, and this is partly where capacity is really important. This person needs to be able to be aware that there is uncertainty, that we can’t be sure whether at some point their suffering could improve or at some point they might adapt to the illness and may have the same symptoms but find a different kind of meaning or purpose in their lives. They need to be aware that they’re making the decision in that environment for uncertainty.

I actually do stand behind even though it creates more restrictions for people with sole mental illness or on Track Two, I stand behind the government panel’s recommendation that sometimes extensive treatment attempts would have to first be undergone in order for us to know whether someone’s more likely to be on the treatment refractory end of that, which would be analogous to irremediable condition. We have no way to know whether they have an irremediable form of the illness without that. We even don’t have a way to know with 100% certainty if they do with that, but it increases our level of awareness of the likelihood of what the outcome might be.

So the other element to that question, which I’ve partially addressed but want to go a little further into is whether suffering can be relieved. I would say that this is actually an uncertainty all across MAiD, Track One, Track Two, and sole mental illness in that someone could have end stage cancer and they could have decided to go forward with MAiD and then they might decide actually they’ve found some meaning in the last few weeks or days of their lives and they want to remain alive and they want to use those last few days in a certain way. So we have uncertainty about whether someone will continue to suffer unbearably in all of those cases. And so we have to take that into account. And again, the person needs to recognize that it is possible that their suffering might improve in the future and that they’re making that decision in the context of uncertainty.

I actually don’t remember if you mentioned this additional concern yet. No, I think that may be something you want to ask about later, but it ties into this a bit with respect to the other concern that often comes up, which is about the difference between suicide and MAiD.

Yes, that’s my next question. So if you wanted to get into that, that’d be great. How can you tell the difference between a request for MAiD and somebody experiencing suicidal ideation?

Again, a very, very deep and complex question. The first thing there I’d want to acknowledge is that by definition, suicide is the intentional ending of a person’s own life. In that sense, because of the language that we’ve used so far, the language that we have to work with, in a sense it is not different from MAiD in that definitional sense, but there are very significant differences between what we’ve conventionally thought of as suicide and what MAiD is.

The conventional way we think about suicide is often a situation where someone has had a sudden stressor or an exacerbation of their mental illness or is in an acute crisis and might be at risk of impulsively trying to end their lives. At the same time, suicide can be planned and it’s not always impulsive, especially in older adults. So we can’t only use impulsivity to differentiate suicide from MAiD, but it is one of the ways.

With respect to the real difference between suicide and MAiD, the government has determined in Carter that sometimes a request for MAiD or a desire to end one’s life due to unbearable suffering can be rational. That’s the concept of rational suicide that people may have heard of before. So the key difference is, is this person making a rational and capable decision? And that involves having a realistic appraisal of their medical situation and their options.

The other thing is that the MAiD process itself requires a certain degree of stability because someone is going through multiple assessors over multiple visits. They are making a request and going through the medical system and not doing this on their own or in a secretive manner. So there are many different dimensions to that. There are additional supports through the process of going through the MAiD assessment, which may lead to some alternative options. And there’s also consistent request over time and the ability to get through that process. So that itself also creates some distinctions between MAiD and suicide.

What I will say also is that some people requesting MAiD can be suicidal. Part of our job as assessors as in any other medical context would be to assess suicide risk. And if someone is at risk of suicide in the conventional sense or if we’re not sure, then that person would need to be protected. Sometimes that means involuntary hospitalization if there’s too high a risk that we assess to be the case. So I’ve had to do that before. There are times where someone is suicidal when they’re requesting MAiD. Most of the time not, but sometimes.

Let me see if there’s anything else I want to say about that. No, I think because we’ve already gone over what we look for in capacity assessments, capacity is required for MAiD and it’s not required for suicide. And so again, similar distinction to some of the others I’ve mentioned.

Thanks, Justine. So final clinical question for me, Justine, before we move on. What do you say to people who are worried about people who will seek MAiD because of their mental disorder, because they’re suffering from living in poverty, or because of being without access to mental health services and other supports?

Yeah, also a really important consideration and a point of controversy. I would say there’s been somewhat of a media storm over the last number of months with, I believe to be fairly biased, accounts in that I’m aware of the details of some of the cases that have been presented in the media, accounts that make it look as though someone was approved from MAiD because of poverty or a lack of housing, but in fact really want to emphasize that that is not legal, that we as MAiD assessors and providers are not permitted to approve someone from MAiD for that reason because of the criteria for MAiD, which required the grievous and irremediable illness.

That said, our system is far from perfect. We do have people living in poverty. We do have inadequate disability supports in many places and for many individuals. I don’t want to dismiss the impact of those kinds of vulnerabilities or what we call psychosocial issues, which may include poverty, housing, risk, violence situations, impacts of severe mental illness and social isolation, just to name a few. So those things do exist and there are people with inadequate resources. The MAiD assessor’s job is to ensure that appropriate resources have been offered precisely for that reason.

That said, in any context, whether it’s sole mental illness or Track One or Track Two, those types of vulnerabilities could exist for anyone requesting MAiD. And also people who are not considered to be vulnerable by standard definitions can still be vulnerable. You can imagine someone who’s used to being in control, who’s been high functioning, who’s wealthy, who has lived a very privileged life, finding themselves in a situation where they’re out of control because they have an illness that they themselves can’t fix. They may define dignity as a certain element of control that they can no longer have and they may be vulnerable for that reason. So we can’t assume that the only vulnerable people are those who are marginalized in some of the more conventional ways.

I would say that these are challenging assessments in that we cannot completely divide someone’s suffering between the illness only or their situation only. Usually it’s the totality of a person’s circumstances that affect their suffering. And we have to take into account the totality of the circumstances. So we can’t exclude someone from MAiD who meets all the criteria and is suffering from that grievous and irremediable condition simply because they live in poverty or they’re on disability and disability is not enough. We have to allow someone to make an autonomous decision within their limitations of their own circumstances. Autonomous decision doesn’t mean there are no limitations. An autonomous decision means that someone weighs their own options within their own circumstances and makes their own choice. So it’s a fine balance. These assessments, again, will often take multiple visits and a lot of gathering of collateral information in order to ensure we’re doing the very best we can to provide people with the appropriate resources and to provide MAiD for the appropriate reasons. I hope that’s helpful.

Yeah, that’s very helpful. Thank you, Justine. So Jocelyn, turning back to the law for a minute. Some people have said that allowing MAiD for those whose sole underlying condition is a mental disorder would make Canada the most permissive jurisdiction in the world and that allowing MAiD for those whose condition is a mental disorder is just evidence of Canada careening down a slippery slope. What do you say to that?

I say that though they’re wrong on both of those claims. So the first has to do with us being the most permissive jurisdiction. We certainly are more permissive than the American states or the Australian states and territories because we are not limited to terminal illness or survival for 12 months, we’re not limited to self-administration as they are in the United States, but we are not more permissive than you find in Europe. So you have Switzerland, Belgium, Netherlands, Luxembourg have been doing this for many, many years. Persons with mental disorders as their sole underlying condition can be eligible for MAiD in those jurisdictions. So we are joining with others who do allow MAiD for mental disorders a sole underlying condition.

Where you see some variability that’s relevant is with respect to the procedural safeguards, do you have to have a psychiatrist involved as the assessor, how many treatments do you have to have tried and that kind of thing. And so what we have to watch for is to see what’s going to happen in Canada when you look at the suite, the suite being the criminal law framework and the procedural safeguards, and then the clinical practice guidelines and clinical practice that will develop over time. That last point always develops over time after the introduction of an intervention, look at the suite of those and see, do we somehow allow more people to have access to aid than these other jurisdictions or with lesser protections? I think what you’ll find is the answer will be no.

Why it’s a little bit different perhaps between them and why they have to look at the suite is because, for instance, in Canada, as I explained before, we have this division of powers. So you have the federal government doing criminal law, you have the provincial territory governments doing health and then self-regulatory. The federal government can’t put certain… needs on clinical practice. And so where in one country you might be able to find it in the legislation itself, we couldn’t do it in Canada because the federal legislation, they don’t have the jurisdiction to get so in the weeds about clinical practice. The question you need to ask when you’re trying to decide are we the most permissive is it in the suite, is it in the practice standard that you need to have a person with expertise? I.e, in some cases a psychiatrist involved in the case.

And so we’re certainly not the most permissive because for instance, Switzerland, no restrictions on mental disorder and the safeguards are less than what we have in Canada. And then in [inaudible 00:52:39], we’re going to be similarly situated because the things that look like they’re restrictive, like do you have to have a psychiatrist or who has to decide whether the suffering’s intolerable or that kind of thing, that shows up in the Netherlands, for instance, in their guidance, in their professional guidance as it will in Canada in relation to our practice standard. So I don’t think we are or we’ll be the most permissive jurisdiction in the country. I think we are going to land. The Netherlands and Belgium and Switzerland will be more permissive on this topic. Belgium and the Netherlands are more permissive than Canada on other issues, mature minors, advanced requests and so on. But on mental disorders, we will be similarly placed.

On the slippery slope argument, we have to not be thinking, “Oh, we’re on a slippery slope because we’re about to allow mental disorders. And we didn’t allow mental disorders as sole and now we’re going to allow mental disorders as sole so that’s evidence of the slide down the slippery slope.” We have to take a step back and we have to go back to Carter, because Carter is the case that Supreme Court of Canada gave us MAiD and the parameter, so picture a circle, is grievous and irremediable medical condition causing enduring and intolerable suffering. No exclusion of mental disorders.

Then what you had was you had Bill C-14, which was the federal government saying, “Okay, this is what the legal framework is,” and they defined grievous and irremediable in a narrow way. So some of the people who were eligible under Carter became ineligible under C-14. So then you had a charter challenge to that because you had to try get back to Carter. So you had a charter challenge to that, which was the Trauscht case. And so we’re down here with C-14. Trauscht sends us back out because it says, “Yeah, reasonably foreseeable, that’s a violation of the charter. You can’t limit MAiD access to people whose natural death is reasonably foreseeable.” So we go back out to Carter.

And then we have C-7, which is the federal legislation response to the Trauscht decision, and it takes away access on a temporary basis for people with mental disorder. And so then what’s going to happen was going to be this year, now it’ll be next year, is that exclusion will be gone so we’ll be back out to Carter. So that is not a slippery slope. That is you had a circle, you narrowed it and you went back out. I think it’s really important for people to understand we are not further ahead. On mental disorders, we are not further down the slippery slope. We’re not more permissive than the Supreme Court of Canada in Carter.

Very helpful, Jocelyn. Thank you. Trying to work our way back to what we originally had years ago, but it didn’t play out that way the last several years. So that’s very helpful.

So my next two questions might seem unrelated to what we’ve been talking about for the last hour, but we do get this question a lot and it’s about MAiD for individuals who have a dementia diagnosis. So some people know that dementia is listed in the DSM-5 that sets out diagnostic categories for mental disorders. Jocelyn, folks want to know, is dementia caught up in this exclusion that we’re now waiting another year for? Or how are things working for people who have dementia under the current law?

So dementia is not caught in the exclusion. So the exclusion was mental illness, not mental disorder. The government was clear to say, “We don’t mean neurocognitive disorders.” So basically they sort of said when people went, “Wait, what? There’s a whole lot of things in the DSM-5. Are you really meaning to capture all of those?” They said, “Oh, no, no, no, no. We didn’t mean to capture all of those. What we meant to capture were the things…” Basically they sort of said that you would expect to see in the domain of psychiatry. So you’re talking about depression and bipolar disorders, schizophrenia, personality disorder, PTSD, those kinds of things that you find in the domain of psychiatrists. Dementia does not fall in the domain of psychiatrists. It is over in this neurocognitive sphere. And so the government was clear they didn’t mean to catch those.

So it’s not caught in the exclusion, but many people listening may think, “Oh, but we’re hearing all the time about people with dementia, they can’t have access. That’s why we want advanced requests.” The tricky bit is that you have to have capacity in order to be eligible for MAiD. And the very thing of dementia is you are losing your decision making capacity. And so if you lose your decision making capacity with dementia, you’re not eligible. So it’s not because of the DSM-5 and dementia being inside that, it’s if you’ve lost capacity. So you have to actually make sure that if you want to have access to MAiD, you get it before you lose capacity.

And so people with dementia are accessing MAiD now, but they don’t have the comfort of what we will call an advanced request, which we can come to later if people are interested in. So bottom line for this point of it, when we’re talking about the mental disorders, dementia is not caught up in the exclusion criteria. So as long as you meet the eligibility criteria, you’re not caught in the exclusion and you can have access. Your problem’s going to be with respect to whether you have capacity or not.

Thanks, Jocelyn, for the legal piece. Justine, clinically, can you speak to what happens if somebody is requesting MAiD currently and they do have a dementia diagnosis, how would that look?

Yes. Jocelyn, I agree with everything that Jocelyn has said in terms of how we might look at that from the legal standpoint also as clinicians. In terms of what that clinical picture would look like, the patients I’ve had requesting MAiD for dementia, I’ve often assessed them over time. The first time I meet them, they maybe have very mild dementia and they’re worried about the future. We used to talk a lot about this concept of 10 minutes to midnight where we’ve talked with a patient about at what point do they reach a point of being too close to lose capacity that they wouldn’t want to continue on taking the risk and that they would want to therefore go through with MAiD before they lost capacity. Now, however, it has changed a little bit in that dementia does have a reasonably foreseeable natural death, especially once you reach a certain point.

So those individuals are on Track One, which means they now have access under bill C-7 to what was known as Audrey’s Amendment, where someone who is assessed and approved for MAiD and then loses capacity can still be eligible provided they’ve signed a waiver of final consent. That waiver doesn’t mean that they automatically get MAiD if they don’t want it. So let’s say they lose capacity and they still want MAiD, the assessor asks, “Do you still want this?” and they say yes, they could still be eligible for MAiD. If they object, if they say no, if they seem uncomfortable with it, then MAiD would still not occur because it’s not an advanced directive, but it is that waiver of final consent. And that has given some people a lot of comfort in that it allows them to actually live longer because they’re less afraid and they’re less likely to get MAiD before they lose capacity. It’s provided a lot of comfort.

I will also like to make a distinction between memory and cognition and decision making capacity. People with dementia typically tend to lose short-term memory earlier than long-term memory. And so it may be that you as the physician can provide the informed consent and then they see you a few weeks later and they’ve forgotten those details about their illness or about how MAiD works. Capacity assessment doesn’t require that they have long-term memory for that information. It requires that in the time of the assessment they can understand and appreciate the information you give them, they can paraphrase it back, they can hold onto that in the sense that they’re able to use that information to make a decision even if they may need a reminder of that the next time you meet.

There is a certain level of severity of dementia where decision making capacity is very unlikely. There are some cognitive tests that we use to measure the progression of dementia and on one of them called the mini mental state exam, typically below a score of 18 out of 30, someone’s unlikely to have capacity. But it’s not impossible and we don’t use those cognitive tests to determine capacity. We still use the same framework for capacity assessment that I’ve already talked about. I think that distinction is also comforting and important to people with dementia to realize that just because they have cognitive impairment doesn’t mean they’ll be incapable. Have I answered that question efficiently for you, Kelsey?

Yeah, no, that was great. And I appreciate you bringing up the waiver. I was going to follow up with a question about that and I think that’s helpful to know how that relatively recent change in the last couple of years does give some extra comfort to people. So thank you for including that.

So we’re going to turn it over to some of our audience questions for the next 10 minutes or so. There’s a lot of them and I know many of you sent them in during your registration, so we’ll try to get to a mix of questions now and questions that were sent in before. So there are a number of people asking about the delay until March of next year now. There’s concerns what if that delay is delayed again, there’s mention of in the AMAD report where the committee will be reconstituted five months before March of next year to determine the state of readiness and if that will lead to another delay potentially. Jocelyn, any comments on that? Any thoughts on where things might be in a year from now?

Right. So a really important thing for people to know is that yes, in the recommendation from the special joint committee, they said, “You should bring us back together again five months before March and let us have a look at this and be sure that people are ready.” It’s really important for everybody to understand that when a committee makes a recommendation, the government does not have to take it. So my hope would be that the government looks at what happened with the special joint committee in the past couple years and decides we have a duty of transparency and accountability to the Canadian public about readiness, but we are not going to meet that obligation through reconstituting this committee because exactly what was, I think, probably behind that question is how dysfunctional that committee was and why would you reopen something that is a process that is so dysfunctional. And if you want to see an illustration of the dysfunction, look at the partisan nature of the dissent and that’ll give you a flavor for flavor for the dysfunction.

So I think what lies behind the recommendation I think makes good sense. You’re saying you need a delay for things to have happened. Well, let’s have a look before it comes into effect, the sunset clause comes into effect to make sure you are in fact ready. I just think that putting that obligation responsibility on the special joint committee would be a mistake. I think what we’re seeing in the house and the Senate in the debates about the delay, the bill that will allow for this year’s delay is a clear demarcation of what readiness requires, especially from a federal level. Because again, I keep going, I’m probably like a broken record, but the federal government has certain powers and the provinces and territories have other powers and they each have their own responsibilities. There are only certain things that the federal government can do, and so in its readiness it needs to look at what can it do.

And so the four things you’re hearing about are one, to have time to review the special joint committee report and absorb that, figure that out, it only just recently came to them so some time for that, to ensure the new reporting requirements which take us into greater information about race, indigeneity, disability and so on, that the new reporting requirements that just came into effect in January of this year are generating good data. The third is the national curriculum that we talked about so that clinicians are being trained. And the fourth is the practice standard that we talked about, that it’s been delivered to all of the colleges and all of the provinces and territories and they can proceed.

So look for that as signals of, “Okay, yeah, the delay took place and we’ve met all the conditions.” The reasons why we had a delay? Well, those reasons have all been taken care of, and so now in March it can happen. My crystal ball would be that if the liberal party is still in government next March, that the sunset clause will be activated and we will have MAiD MD-SUMC. Given what happened this past week and the statements that have been made, if the conservative party is in power, then the sunset clause will not take effect and indeed we’ll be looking at the prospect of access to MAiD being rolled back. So that’s the future.

Thank you, Jocelyn. A question for Justine about capacity assessments. So capacity assessments happen all the time during May. A person needs to have capacity during those assessments. And the depth of that investigation, my understanding will vary depending on the person’s situation. Do you see there being a standardized approach to capacity assessments for people whose sole condition is of mental disorder or do you think it will also be very case by case?

That’s a great question in that there are standardized tests for capacity assessment in general. The gold standard is considered to be the MacArthur Competence Assessment for Treatment, which was not developed for MAiD. But it provides, I find, a very useful framework by which to conduct those assessments. It is the MacArthur that recommends that someone with a more complex situation demonstrate greater abilities that the rigor goes up. The developers of the MacArthur actually don’t approve of the use of their test for MAiD situations saying it was primarily approved for treatment and research and was not specific to MAiD. I still personally believe that it’s an excellent framework and that I don’t think that decisions for MAiD are that different at all from other highly consequential medical decisions.

There are no capacity assessment tools that have been well validated in that same way and also developed specifically for MAiD. I think the tools are useful. I think taking them to account as part of an assessment helps guide us, but every capacity assessment tool has its limitations. And so this is why a case by case basis with guidance and framework but with some flexibility is really important. For example, the MacArthur is very cognitive. It doesn’t look at the person’s emotional state or their values or their life narrative for example. There is an interesting test known as the [inaudible 01:08:25], which was developed to also take into account the assessor’s state, the assessor’s values. I think that’s really interesting too, and that relates to the principle of self-reflection, but I think these will always be aids to the capacity assessment rather than a standalone capacity assessment.

Great. Thanks Justine. So one final question before we go for today. So maybe we’ll start with you, Jocelyn, to get the legal piece and then move on to Justine to chime in on the clinical piece. So somebody’s asking about two different pieces that are being discussed in the MAiD space. One is mental disorders, the other is mature minors. So this person’s asking if mature minors with a mental disorder would be considered potentially with the legal changes coming up. Jocelyn, any comments?

So one of the things that the special joint committee looked at was this issue of mature minors because as I said at the very beginning, recall you have to be 18 in order to be eligible for MAiD. That is inconsistent with all other healthcare in the country. We have the concept of a mature minor, which is somebody who’s under the age of majority, so under 18, but who has the decision making capacity, the same decision making capacity as somebody who’s 25 or 45 or 85. For all of their healthcare decisions, they actually have decision making authority. So they get to make decisions that have incredible consequence, including death. They can refuse life-sustaining treatment if they are a mature minor.

So the special joint committee did recommend as every committee, an expert panel who has looked at this issue in the past and there’ve been a number of them, they’ve all recommended that mature minors be the basis for eligibility, not chronological age. And so the government will be looking at, deciding whether they want to take that recommendation and allow access for mature minors. If they do, of course, and if mental disorders as a sole underlying condition comes through, you then would have those two things come together and you might have a mature minor who is seeking access on the basis of mental disorders as sole underlying condition.

But I think you have to think then about what Justine said about the need to have tried all kinds of treatment. You’re 17, you’re not going to have tried all the kinds of treatment and had the time for adaptation to the symptoms and had the time to see whether your condition resolves itself independently of treatment as depression can do for instance. So I don’t think that pragmatically you’re going to see cases of mature minors with a mental disorder as their sole underlying condition because of the requirements with respect to long-standing attempts at treatment so that the clinician can actually say, “Okay, looking forward…” I have to be able to look backward at treatment attempts in order to look forward and say, “What do I think is going to happen?” And that’s a part of in the incurability assessment.

So I think they could come together in a request. I don’t think they’ll come together in an actual provision, although maybe in extraordinary circumstances, Justine would be able to come up with a circumstance in which that might happen in the sense that it wouldn’t be excluded by law. I think it’s much more that it won’t happen because of the pragmatics of what is required in order to be found to be eligible especially in the context of mental disorder as a sole underlying condition.

Thanks, Jocelyn. Anything to add to that, Justine?

Actually, no, I have nothing to add. I would see it the same way as Jocelyn. The issue is the life experience with the illness and number of treatment attempts tried wouldn’t be possible at the age of 17 or 18.

Thank you both. So that wraps up our time together this afternoon. I want to thank you for everything you shared with us this afternoon. It’s been so informative. We have a lot of thank yous in the chat and I just wanted to share one of them with you before we go. So this person says, “A sincere thanks to the two presenters. Spoke so well and provided such articulate and straightforward responses. Very much appreciate their expertise and the huge amount of work that they are doing on this topic.” And I and the team here certainly echo that and thank you for sharing that with us today.

Please, attendees, if you can take a few minutes to fill out our survey, that would be appreciated. And we will see you next time. Thank you both again.

Thank you for having us.

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Take care. Bye.

Bye.