Regional Spotlight: Death and dying in Quebec

In October 2021, we hosted a webinar with a focus on death and dying in Quebec. The conversation touched on general attitudes about death and dying in Quebec and common misconceptions about medical assistance in dying.

This blog post will highlight the key takeaways from the webinar.

The panelists

Dr. Benjamin Schiff is an MD and Assistant Professor at McGill University in the Department of Family Medicine. He has been a MAID Assessor and Provider since 2016 and is a member of the MAID Resource Group College of Family Physicians of Canada. Dr. Schiff is a full-time Family Physician working at St Mary’s Hospital in Montreal. Most of his time is spent as a hospitalist, including working in Oncology. He has a life-long interest in medical ethics, especially around end-of-life care.

Dr. Georges L’Espérance, FRCS(c), M. Sc. (Adm. Serv. Santé), Neurosurgeon: After he obtained his medical degree at the University de Nancy (France) and had a 3-year formation in neuroradiology, Dr. L’Espérance pursued his neurosurgical training at Laval University, Quebec City. He practiced neurosurgery in Québec from 1984 to 1990, then in Montreal, mostly in a tertiary Traumatology Center, Hôpital du Sacré-Coeur de Montréal. In 1998, he completed a Master in Health Services Administration at the University of Montreal and received the Robert-Wood-Johnson’s award in 1998. While involved in academic medicine, he has been a co-investigator in several clinical studies in neurosurgery and functional rehabilitation and presented more than fifty scientific communications; he gave multiple lectures on scientific or ethical questions. He is currently an associate clinical professor at the Faculty of Medicine at the University of Montreal. In 1999, with Dr. François Sestier, he founded the medicolegal cursus at the faculty of medicine at the University of Montreal. He has more than thirty years of experience in Independent Medical Evaluation. His neurosurgical clinical experiences and his personal reflections naturally led him to question the purpose of medicine and particularly ethical questions, in particular over-medicalization and end-of-life issues. Since November 2014, he has been president of the Quebec Association for the Right to Die in Dignity (AQDMD – Association Québécoise pour le Droit de Mourir dans la Dignité) and now devotes most of his time to it and is very involved in providing the ultimate compassionate care: assisted medical death for those who want it.

In your experience is death something that is commonly or openly discussed in your community?

We are more open to end-of-life discussions than we were 10-20 years ago. We speak more about medical assistance in dying now, especially since the passage of Bill C-14 and the legalization of MAID in 2016.

Because medicine has become more patient centred, we have become more comfortable discussing end-of-life options.

Both panelists take every opportunity to talk about and educate patients, family members and colleagues about end-of-life choice because there is still room to make end-of-life conversations the norm.

How have the discussions about death and dying changed in the past 5 to 10 years?

Duty of care has expanded from a focus on cure to that of care of the patient, with the goals of care central to the approach, including various clinical options at the end-of-life including comfort care and MAID.

More patients are educated about their health care options – pain-relief, palliative care, palliative sedation, MAID – so discussions come about more easily than in the past.

What are some common misconceptions about the MAID process?

• That it is an easy choice. The decision to decide you don’t want to live anymore is a difficult one even for someone who is suffering.
• That it is easy for providers. MAID assessors and providers take the role very seriously and want to support the patient with any decision.
• That everyone knows about MAID. Many Canadians still do not know that medical assistance in dying is legal, so it is important to let patients know about all their health care options.
• That someone else can consent to MAID for you – to be clear only YOU can consent to MAID. Requesting MAID, as in making a call to a care coordination service, can usually be done by family members, friends, etc.
• That you can request MAID and receive it in the same day. This is not completely true or false.

There are safeguards and processes in place during a MAID assessment. It is also important to remember that the decision to request a MAID assessment often requires a great deal of reflection and time to make before bringing it up with a health care provider.

But in practice, if you have made the request, that you have been evaluated by the first AND the second doctor (at this time only doctors in Quebec can provide and evaluate patients for MAID), and that you have been judged eligible, all this in the same day, then you could have MAID the same day.

Note: The second evaluation may have been done before the first one, for example by the treating physician.

What is the feedback you received from someone who attended a MAID death, what helped them and did not help them with their grief?

There is an opportunity to say the things that you want to, if you want.

The patient and the family are at peace.

Both physicians have only ever received positive feedback.

Do you experience grief in your work? How do you navigate this, particularly after the death of a patient?

We are empathic people, so it is natural to feel grief.

It is difficult when a patient dies that you have known for a long time.

Grief is often experienced with the family after a death.

Health care teams support each other through grief.

If you are experiencing grief, don’t go through it alone.

Why can’t nurse practitioners assess or provide MAID in Quebec?

The provinces have no competency on the criminal code which is a federal jurisdiction. That is why in Quebec the law was under health care regarding end-of-life care. The law was enacted in 2014 and the legislator was on a very narrow line and cautious not to place caregivers, namely nurses, at risk to be prosecuted under the criminal code (federal), not changed at that time. So, MAID has been considered only as a medical care under the responsibility of doctors and did not encompass nurse practitioners. Then came the unanimous decision of the Supreme Court (February 2015) who obliged federal government to change the criminal code. The Quebec’ law was not amended in 2016 when MAID became legal in Canada with the introduction of the federal assisted dying law via Bill C-14.

Both panelists expect that nurse practitioners will be able to assess and provide for MAID in Quebec in the near future.

How do you access MAID in Quebec?

All referrals are processed through the local community health centres (CLSC) organization in Quebec.

Data about MAID from Quebec

April 1, 2020 – March 31, 2021

2426 people in Quebec had a medically assisted death (3.3% of all deaths)

91% of patients were 60 years old+

83% of patients had less than six months to live

Medical conditions

73% Cancer

8% Neurodegenerative or neurological disorders

6% Cardiovascular

5% Pulmonary

8% Other

Note: Data collected before the new criminal code was modified with Bill C-7, so it is normal that the vast majority of conditions are cancers.

Location of the medically assisted death

48% at hospital

39% at home

8% long term care facility (CHSLD)

5% hospice

On average MAID was administered 19 days after the official request

93% of MAID requests in Quebec had both a physical and spiritual/psychological motivation.

Those who requested but did not proceed:

• 33% inquired but did not follow through
• 34% changed their mind before administering MAID
• 17% cancelled their request
• Remaining, unknown reason

1121 physicians participated in the MAID process, an 18% increase since 2019-2020.

So to get us started, Benjamin, what inspired you to enter into this field?

So I would say just to give a bit of background, although I’m a full-time family physician, I primarily work or at least 50% work in a hospital in inpatient wards. And in fact, one of my earliest memories is a elderly woman who was suffering from ALS, so neurological issue. And she had something that’s called Bulbar ALS, which resulted in her inability to swallow and to speak. And basically she sort of slowly and inexorably got weaker and weaker until she passed away with her family around her. And it was clear that she was getting weaker, that she was suffering and limits in terms of what we could do with palliative care, otherwise in terms of alleviating her distress and her family’s distress.

I spent a lot of time, unfortunately, with people at the end of their life suffering, dying. I spent a lot of time now on the oncology ward at St. Mary’s as well, and it was clear to me that people should have that ultimate right. I’m a very firm believer in autonomy and that we should be choosing what happens to us and at the very end of our lives up until recently, we didn’t get to make that ultimate choice. And so I think I was inspired and saddened and disheartened in many ways, by some of the things that I saw.

I would read a lot about of what was happening overseas, particularly in Netherlands and their experience. And I felt that it was really important that we have the opportunity to offer that kind of care either at the end of life, or as things have evolved, even for people who may not at the end of life, but are suffering. And whatever palliative or other care can be offered to them, unfortunately is not enough to alleviate their suffering as they perceive it, and that needs to be more that we can offer.

So that’s how I ended up getting interested. I was interested in it before it became legal. I was talking about it and discussing with colleagues and residents and I was very happy when the opportunity arose for this to finally be offered to patients as Dr. L’Espérance, George is going to be sure talking about patients who are suffering and have that and should have the right, and now have the right to request the kind of care as they perceive it to help them at the end of their time.

Thank you for sharing. [foreign language] Georges, [foreign language]?

[foreign language].

[foreign language].

[foreign language]

[foreign language] And Ben, so same question. In your experience, is death something that is commonly or openly talked about within the community?

So I’ll speak, I guess, more towards my hospital community and I would say, yes. It’s hard to know sometimes what sort of comes first. I think having [foreign language] become legal has certainly allowed that discussion to be placed more openly. I know and I’m sure Dr. L’Espérance know the same thing that we’ve tried to bring this topic to our colleagues and help them become more familiar and to discuss it. But what I found in particular is that among nurses it’s been something that’s become more comfortable and more commonly discussed. And I think they, as a group, are taking more, again going back to being patient centered, which is the essence of nursing as well as medical profession. But in particular, I find that’s emphasized in nursing to really identify and support and advocate on behalf of the patient.

And when they see patients who are suffering, who they feel more needs to be done, it’s more common and more comfortable to have these kind of open discussions, not necessarily about me, but just in general about how to provide better care and better comfort to patients and families who are suffering. So I think there has been a more open discussion. I think that the legalization to me has allowed that to come into the mainstream, but I’ve been very happy to see that it’s … In the past, if I were to bring that up, there’d be more discomfort among colleagues and medical colleagues as well, and now I feel that’s changed significantly.

I agree.

Yeah, that makes a lot of sense. And the next question is sort of very similar, so I’m not sure if there’s anything else to add. If not, that’s no problem, but it was just how, I guess, have those specific discussions around death and dying changed specifically over the past five to 10 years or so?

The only thing I would say is that, in the past, I think there was again, a bit of reluctance, particularly, let’s say, with some medications. If you would be ordering whatever it was, being morphine or any, I think that you might choose to help somebody at the end of their life, there may have been a little bit reluctance and, “That’s a dose that you’re using, or why are you using that, or …” Sometimes there would just been a little bit of pushback I found, whereas now that’s not the case at all. In fact, it’s often the opposite where they would come to you and say, “Can we do more? This person seems to be suffering. Is there anything more that we can do?”

So I don’t want to get into too nitty gritty details, but clearly there’s been more of an acceptance of the fact that we owe our patients at the end of their life, as much as we owe them when they’re alive and when they’re thriving and when they may be going home as when they’re not going home. And so, that care doesn’t stop, and regardless of whether we can, “Cure somebody,” we have that duty and obligation and moral ethic and otherwise to provide care toward all through their stay and all through their life. And I think that’s becoming more and more clear as time goes on.

That’s great to hear, of course. So Georges, [foreign language]

[foreign language]

[foreign language]

[foreign language].

You should be able to share.

Okay. [foreign language].

[foreign language].

[foreign language].

[foreign language] Yesterday. [foreign language].

[foreign language] I just took snapshots of a couple of other slides. I think, we both got the information yesterday, exactly the same time, so it was very timely. So I’m just going to share just a couple of things.

Perfect.

Let’s see. Start broadcast. Sorry, it should work now. Okay. So I just wanted to give you an idea about in terms of how they define or how we look at the reasons for people requesting MAiD. And I think, it’s important to know that if you look 93% of the case is both physic physical and sort of spiritual. And I think, that’s a very important part that we probably will come back to talk to a little bit later, but that this is not about physical suffering alone. This is almost always 93% of the time, there’s an element that I think for most people and I think Dr. L’Espérance and I know that in terms of our work, is related more to the spiritual aspect of things or to the psychological part of it, which becomes as important, if not more important for most people.

And just again, sort of showing an idea about how long people are waiting in that you see the vast majority of people are less than 90 days. There’s very few that are more than 90 days. That’s the blue one, that’s 3%, but most of these things, most of the … Once the request has been made, the delay is almost always less than 90 days, and more often than not even less than that, often less than 10 days. Which again goes back to what was being mentioned before about certain things that have changed in the law for the good, in terms of not having to wait 10 days anymore, which I think was a big impediment. It made things very difficult and if we do talk about it a little bit more, also in terms of not having to require final consent.

So this commission is really something that’s quite unique and I think it’s very beneficial and helpful to us as practitioners and a sense of all the lawmakers to get a sense of where we are and where we might need to go to make perhaps changes or improvements as time goes on. But I’m very proud to say the Quebec’s been at the forefront of this from the beginning and I think it continues to be able to demonstrate an involvement and a reasonable oversight to look and gain information, to continue to improve the services that we offer to our patients.

Thank you.

I can show another slide if you want, and I’d say it in English and French. Can you give me-

Sure.

Perfect.

[foreign language] here. So right now, this is … You see here the progression of medical aid in dying and then in the last years, [foreign language]. There’s a kind of plateau in Belgium, Holland and … how do you say that in English? [foreign language].

Netherlands.

Netherlands, thank you. [foreign language] In the next year, with the new law, probably this number will still going to increase and I think that we’re going to get somewhere around four to five, 4.5 or 5% of MAiD for all the death in, in Quebec. That’s my provision here. I don’t think that with the COVID, we will have very much a change in that. Perhaps we will have less death because of the ratio, because we now know that in the year of the pandemic, there’s an over mortality of 12,000. So if you have moreover mortality of 12,000, well you have less patient that had MAiD. So for the next year probably, there will be a kind of stabilization, even with the new law and then in the next year, we’ll see where will be the plateau. [crosstalk]

Sorry, just to emphasize that, particularly because that over deaths were in the type of population that would more often be asking for MaiD, which would be more elderly patients in the vulnerable population like cancer patients, who were disproportionately represented by the deaths from COVID and who tend to be, as we saw earlier, the ones that tend to be the highest, the greatest proportion of patients that do request MAiD. So I completely agree. It’s going to change things temporarily anyway.

[foreign language]. I just said that with the new recommendations for mental health, I don’t think that it will be a highest number of death, because it will be very, very few patients that will be agreed for MAiD. I don’t know if Dr. Schiff agree with that.

No, for sure. I think that’s … I mean, that remains to be seen. I mean, there’s clearly a large, unfortunately a large percentage of our population that suffers with mental health issues. But I think that certainly at the beginning, when there are provisions and the law for that, they’re going to be very restrictive and very protective because it’s the most vulnerable, probably of all the people that we see because of trying to differentiate the suffering and their mental illness, which unfortunately can impact on how they perceive and how they communicate and how we are able to evaluate.

So there’s going to be a lot of … I think it’s going to be a lot tighter than it is for some of the other recommendations and other things within the law. That probably will change with time as we get more comfortable, as this happened with the first section, first part of MAiD. But I think certainly at the beginning, it’s going to be restricted to a very small group and very well defined group of people to begin with.

Yeah.

So I agree. [foreign language]

Last slide for just to complete that. This is the last year, ending at the end of March 2021. So cancer, 73% of patient and neurodegenerative or neurologic disease, excluding SLE and that kind of stuff, except if the patient was in the last month of his life. Probably this number here will increase in the next year because of the new law. And you can see, it’s very low beside cancer. Cardiovascular and pulmonary disease, these categories are … Those patients were at the end of their life. It’s with a very advanced degree. So [foreign language]. Dr. Schiff, you want to add something in English?

No, I agree. I think, some of these things may change with time and I think for some of the later questions, I may have some other comments of that, but clearly I think cancer will always be the most common or one of the highest proportion within this group. Although the others, I think will increase with time, but I think cancer will always be the highest proportion.

Yeah, and the second category that will probably increase is … That category is here of the neurodegenerative diseases. So the patient won’t have to wait up to the end of their life if they want to have MAiD before. But you know, it’s not a very large part of the patients. [foreign language]

[foreign language]

Okay. Thank you for all of that. It’s really helpful to have the visuals as well. So I’m sure everyone really appreciates that. Okay, so the next question is, what are some common misconceptions about the MAiD process?

So I’ve thought about this sort of long and hard and in terms of what you mean by process, by I’m going to just sort of list four things. One of them may be a little controversial, but you know what the heck. It’s nothing wrong with that. So I think the first one I would say is that the people think it’s an easy choice for patients. It’s never an easy choice for patients. Patient that makes this decision has thought about it, has a reflected on it. I mean, the decision to decide that you don’t want to live anymore is, no matter how much you’re suffering, no matter what’s going on, it still runs counter to most of how we see and perceive our lives and what we want. So I think the people thinking that the law is there and so people just sort of make that decision off the cuff. That’s not true. It takes a lot of courage and it requires a lot of reflection.

I think the other point that it’s easy for providers. It’s not easy for providers and nor are we as providers just sort of so happy to say yes, no matter what, that we just say yes, no matter what. That’s not true at all. We take this responsibility very seriously. We are there to help patients, but we also understand that there’s more than one way to help somebody. And that it’s important that we have that responsibility to reflect and understand the process, the meaning and all that goes into that request. And so, as much as we are happy to be part of this and to support our patients, it’s not that we don’t understand the significance and gravity of it.

The third point, which again, may be a little controversy, but there’s this notion around palliative care and whether this is part of palliative care or whether it isn’t. From my perspective, number one, no matter how good palliative care is, it’s not always going to be able to answer all the needs of patients. There are just some things that cannot be an answered with even the best palliative care. And from my perspective, I think people sort of see palliative care, some people see this distinct and separate from end of life care or MAiD. I do not. I don’t think it is and I think that, that’s something that can be discussed and I’m not sure other people in the audience how they feel about that.

And the last point I would say is that, and that may affect the numbers going forward is that this notion that somehow now that it’s been around for four years, everybody knows about it. All the patients know about it. So we don’t need to bring it up. We don’t need to mention it because if they don’t mention it, that’s clearly not something that they want. And again, that’s not true. That just happened to me a few months ago, where somebody didn’t seem to be aware of the fact that they might be eligible or they can ask for it, for whatever the case. And I think particularly as the law changes, not everyone understands what that’s involved in. So the belief that somehow we don’t need to talk about it as practitioners. That somehow if patient brings it up, they bring it up. If they don’t, they don’t, it means they don’t know. I think that’s also a bit of a misconception.

I think there’s still that as part of any kind of discussion that you have with a patient, when you discuss options for neurosurgery, options for blood pressure, options for end of life care, we have to be able to mention some of the things that perhaps patients aren’t aware of, obviously not in a coercive or suggestive way, but just to make sure that they understand all their options. So I think the misconception is that somehow we don’t need to do that because everybody’s aware. So those are kind of the four things that I would sort of briefly say. I’m not sure it’s exactly for the question, but it just were some thoughts that I had, reflecting on this.

No, that’s great. Thanks for sharing those and outlining them for us. [foreign language].

[foreign language].

[foreign language] Now they say, thank you for helping them with their suffering and the families say, thank you for helping. So I completely agree and there’s nothing like that look on their face when you say yes, they’re eligible and they just have that comfort of knowing that there’s a point when their suffering will come to an end and somebody’s heard them. Somebody’s heard them, somebody’s listened to them and somebody’s appreciating what they’re going through and acknowledging what they’re going through and is there for them. So, I agree completely.

[foreign language]

[foreign language] goosebumps. Thank you for sharing. [foreign language]

[foreign language].

[foreign language]. Thank you so much for that, Georges. So same question. Have you received feedback from individuals who experienced a MAiD death, about what they found helpful or unhelpful as they navigated their grief?

So there’s so much to say, and I’m conscious of the time. I’ll just say that I was trying to organize some rounds of the Family Medicine Forum, which is a national forum for family doctors. It was in Montreal one year when we could still meet in person. And I wanted to help people understand why that was important and hearing it, not through the words of a practitioner, but hearing it through the words of a family member who had experienced it. So I was there with another colleague of mine from Toronto, and this daughter of one of the first people that I provided MAiD for, eagerly agreed to be there, to share her experience and to share how important it was for her to be there with her dad at the end, at the time and the place that they chose together. She was there with her siblings who were coming in from France.

Not only that, but just to piggyback onto what Dr. L’Espérance was saying, it’s not only the chance to be there and make sure you’re in the room, but it’s also a chance for people to say what they may not have had a chance to say. And in particular, in this case, it was actually the patient who was dying, who was comforting his family. They were beside him. They were able to be in the room, holding his hand, being very close, and they were crying a little bit. And he was with them and saying, “It’s okay. [foreign language].” He was just so incredibly calm. He was comforting them. I mean, which is just not something you normally have a chance to see, because oftentimes, by the time people are really at the very end, they’re not able to communicate or provide any comfort to their family around them.

So just another positive thing, and I think that’s part of what made the experience for her so positive that she was willing to share that with other people at a conference, something very personal. So I’ll just say that I’ve never received anything but positive feedback. And even if it’s not verbalized, you can sense it. You can sense it in the room. You can sense the spirit and the warmth that’s there when families get to be together with each other, to help them through a difficult time. So I’ll just stop there.

Yeah. That’s beautiful and clearly beyond words at that point. So thank you for sharing that. Okay. So the next question is, do you experience grief in your work? How do you navigate this, particularly after the death of a patient?

So that’s … I mean, grief is part of what we do. Grief is part of caring, particularly in my work and I’m sure with Dr. L’Espérance, is that the work that he does. We live it, I’m not going to say every day, but I’ve certainly lived this for all of my years of practice. I worked in the emergency room. I work on the wards. I look after people who are dying and it’s very different for different people. There’s some people that you feel closer to than other people. There’s some people you feel more attached to, whether they’re patients that you’ve known for a long time. Sometimes the grief … In fact, more often than not, the grief is not with the person who passes, but with the family, because I think something that we all as human beings can identify is with loss, we’ve all experienced it at some point. If we haven’t, we will loss of somebody that we care about, whether it’s a friend, family member, sometimes it’s a pet, something that’s been important to us.

So I think as human beings, as empathic people, we can identify and understand what it’s like for family members to say goodbye to somebody they care about. Even at that moment when they know it’s the right thing and that’s often the struggles and the challenges and the courage that family members have, because they’re making decisions and they’re supporting the decision of a loved one, even though they know that they’re not going to be with them anymore, but they know that that’s what’s best for their father, mother, et cetera. So I think some of that grief is, is around watching other people suffering. Again, we feel that.

I’ll say that, when I started doing this, it was it wasn’t easy just because it also runs counter to what we’re always taught as physicians, that we’re supposed to be there to keep people alive, not to help them pass. And even though it’s something I felt, I had no doubt was the right thing to do, I did have some struggles at the beginning. Fortunately, I have people around me that support me. I have family at home and I work with an amazing team at the hospital. And so we cry together sometimes and we hug each other, because that’s part of it. Part of it is the emotion and if you don’t have the emotion, then I think you’re not able to really provide that kind of care.

So, is there some grief? Absolutely, there’s some grief. Sometimes it’s easier. Sometimes it’s harder. The best piece of advice I could say is don’t go through it alone, because you’re not alone, and hopefully you have friends, family and team around that can share. If you have a team that’s doing this with you, they’re going through the same thing. There’s no point in trying to keep it to yourself. Anyway, I could go on. Dr. L’Espérance, I’m sure has a lot of insights to add as well, but whatever grief there may be, it’s still an incredibly rewarding thing to be able to help somebody to end their life with their suffering, and I would never do anything differently regardless.

That’s awesome. Thank you for sharing that. [foreign language].

[foreign language].

[foreign language] So thank you both. [foreign language]. Thank you for taking care of the questions today. And we have some audience questions that have come in. That wraps up our planned questions. So there were a few audience questions. We’ve got a few minutes left. So Sam, are there any that you want to start with?

So one here, which can be answered in either language, why are nurse practitioners unable to provide MAiD in Quebec, whereas in other parts of the country, they are allowed to provide MAiD?

Benjamin?

I don’t know the answer to that question. I completely disagree with that. Certainly in parts of the country, they can assess or provide some places they can only assess, but not provide. I have the privilege of working with some amazing nurse practitioners where I am, who are just as capable to make assessments, do provisions, provide whatever care and comfort that’s necessary. And I think it’s going to change because I think in general, Quebec is moving forward to liberate nurse practitioners from having to be sort of attached by the umbilical cord to physicians, they’re beginning [inaudible] independence. So I would expect that eventually that’s going to happen, but the answer why, I don’t know what the answer is.

Well, I don’t know the answer, but I know the explanation because the law in Quebec has been made in 2014 and at that time, the criminal code was there. So it was only to protect the doctors. And so, the nurse wouldn’t be able to do it because it was for the doctors, that’s why. And it was on the thin line of the Health Services. [foreign language] When federal law went out in June 2016, [foreign language]. Short answer, because the law in Quebec was before that on the healthcare, and little bit shorter answer is that because government of Quebec didn’t do anything since the last four years, five years now to change that.

Thank you both. One question that we didn’t actually get to, that we’ve received quite a bit before, during our registration and then while we’ve been live is, folks who are having trouble finding a doctor to assess them in Quebec, what can they do? Who can they go to? Are there doctors required to assess them? Either one, feel free to start.

Georges, [foreign language].

[foreign language].

[foreign language].

[foreign language]. Go ahead Benjamin.

So I’m not sure if everyone understands the way it works on Quebec with that there’s a group into [foreign language] that’s are set up. So all the requests that come through, even if they go to a physician directly are referred always to this group, which are divided according to all the CISSS and CIUSSS throughout Quebec. So in fact, there’s always a bit of an oversight. There’s always a group that reviews and looks at things. So just so that it’s clear, it doesn’t go directly to a physician. The physician sort of unilaterally makes an assessment and organizes things. It’s always done with that kind of over-sighting group behind them.

So I’m not sure if that’s what the question was looking at, but that was again, part of what was put into place in Quebec. And again, I would say, having been aware of a lot of the challenges across the country, where many physicians practice in areas where they don’t unfortunately have a lot of support from their local community or government. That’s another thing when the law was created, to make sure that now there was always something in place, to make sure that people who were going to practice, would have the support behind them. So that is something, it may seem a bit onerous, but in fact, it is a beneficial thing, particularly in cases that may be more difficult or challenging or less clear, but there are these GIS they’re called, Groupes Interdisciplinaires de Soutien, set up throughout the province to receive and to process these requests.

If you agree, I will answer to one question I see regularly here from Lorna, how does medical aid in dying apply to for people who have severe Alzheimer’s disease lasting for many years, but do not appear to be suffering from pain? It’s important because now with the new law, C-7 since March 2021, a patient who have an Alzheimer within grade four or five, but still apt to decide for himself may have medical aid in dying, but with the 90 days of reflection, as long as he is apt, but he will lose some weeks or months of a pretty good life because he needs to be apt to have medical aid in dying.

What is on the studying table now and the commission just closes her work yesterday and we’ll have the report in November is, if a patient have the diagnosis of neurocognitive disease, degenerative disease, he would be able to ask for MAiD when he will not be apt anymore. That’s what is on the table now and that’s where we are going. That’s what the 86% of the Quebecois and 80% of Canadian wants. I agree with that in the last [foreign language] data that was done couple of weeks ago.

And that sort of comes out of a little bit of what’s changed in the law too, which is that prior to all of this, you had to be apt at the very end. So even if you made a request and you were apt up until five minutes before you went in the room, if something happened, if you had a stroke or you had some other medical process that took place, you could no longer consent. At the end, you were no longer eligible. That was one of the major changes that took place with C-7, which I’m sure you feel the same way I do, which was a very, very, very important change, because it created a lot of challenges sometimes in terms of how you manage people’s pain and other things that you felt might interfere with their consent and patients being afraid of this …

Anyway, it was something that was quite challenging and in many cases, and it’s something that all of us are very grateful for, but it’s still not something that applies to people that are at the 90 day track. It’s only if you’re in the sort of end of life or reasonable foreseeable natural death track. So again, I think everything’s going to keep changing the time. There’s always feedback that’s coming through practitioners and to continue to see what are the impacts, because as we know when the law’s created, we can’t always anticipate all the consequences. And so as it comes into being and the practitioners have a chance to see what’s happening, feeding back to the legislature and the commissions and hopefully they can respond to what may well have been well intentioned new laws that don’t necessarily have the consequences that they wished. And so it’s ever evolving and growing and changing, and fortunately people are also there to help guide us through that. So personally, I’m quite appreciative of that.

[foreign language] For people of the Orthodox Jewish Faith and who request MAiD, will this procedure affect in any way their right to be buried in a Jewish cemetery? I don’t know.

I’m not sure. I think, one of the things is that it depends who knows, because they don’t necessarily need to know. As we know certain things don’t necessarily get shared. We don’t write that on the medical certificate. So in Quebec, we don’t have to write that they’ve received MAiD. So depending on what somebody decides to share or not share. I mean, there’s a whole issue around, I don’t know all the details, but I know that around Orthodoxy, suicide is … And in fact, there’s a great aunt of mine that was not allowed to be buried in the Jewish cemetery because she had killed herself many, many years ago.

So again, a very strict religion for sure, that would be an issue. The question is always who finds out and how do you know that? So I can’t go into more detail than that, but I do know that we don’t have to share that information and that information is not on the death certificates when we complete them. So it’s not something that funeral homes would have access to. They would just know that the cause of death would’ve been cancer or whatever other condition that the person had. And the specific final details are not known to anybody except the people that were there.

[foreign language]. So there is in the law in Quebec and I think it’s the same in the federal, there’s a part of the law who says that, nobody can have his benefit, death benefit if you want, life insurance be denied because of medical aid in dying. It’s in the law. So, it’s not written, it’s written anywhere … It’s not written anywhere in the file that the patient had made, except in the very private medical file.

Thank you. Yeah, we actually get that question quite a bit. Folks asking if it’ll be on the death certificate, so thank you for clarifying that. I see that there’s still lots of questions. In the essence of time, I think we’re going to end here and I want to thank Dr. L’Espérance and Dr. Schiff for coming this afternoon and sharing all of your thoughts and opinions and expertise with us and everyone who is here. If you didn’t get a chance to … If your question didn’t get answered, please submit it to support@dyingwithdignity.ca and we will follow up with you individually. If we need to reach out to our panelists today, we can do so to help answer your questions. So [foreign language], thank you again, and everyone have a great afternoon and thank you for coming.

[crosstalk] Thank you for the opportunity to … Sorry Georges, but I was just going to say thank you for the opportunity to invite us and to have a chance to share our experience and hopefully provide more information to those of you that are looking for more information. So thank you very much for the invitation.

Same thing. [foreign language]

[foreign language]. Sounds great. We will do that.

[foreign language].

[foreign language].

[foreign language]. Thank you so much. Thank you all for coming.

[foreign language].

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