A well-attended Academy Spring Talk at Innes College featured Dr. Jean Marmoreo, a Medical Assistance in Dying (MAiD) assessor and provider since the enactment of Bill C-14 in 2016. Dr. Jean has been a family doctor for over 46 years, with an eclectic resume ranging from academic and author to trekker and marathon runner. She offered a comprehensive and thought-provoking examination of “the journey so far and the road ahead” in MAiD in Canada. Her presentation used beautiful visuals of vast and remote regions of Canada as a metaphor for the journey that the medical community and MAiD patients have followed in the last several years.
Dr. Marmoreo started by examining statistics on the application of Medical Assistance in Dying. In the three years from 2019 to 2021 the number of MAiD deaths slowly rose as the program became more established. By 2021, MAiD accounted for 3.3% of all jurisdictional deaths, consistent with roughly 4% in European countries. Quebec and British Columbia were outliers at roughly 4.8% and Ontario was slightly below the average at 2.7%.
She talked about a significant change that occurred in 2020 as a consequence of a Quebec court challenge. The removal of a mandatory NDRF (“natural death reasonably foreseeable”) criterion, viewed by the court as denying Canadians the right of bodily autonomy, opened up access to MAiD to people who might not have been previously eligible. As a consequence, people who apply for MAiD now fall into two categories, Track 1 and Track 2.
Criteria for both forms of MAiD request changed as a result. The criteria for Track 1 (NDRF) were eased in requiring a signed formal request by only one witness, the allowance of a care worker to act as witness (as long as they were not in the will), the removal of the 10-day waiting period, and the acceptance of a written Waiver of Final Consent (WFC). The WFC was particularly reassuring to patients who feared that they might become incapacitated in the time between choosing MAiD and the moment of having it administered. Statistics showed that this track was taken mostly by patients with cancer (66%), with cardiovascular and other conditions in lesser numbers.
The criteria for Track 2 (Natural Death Not Reasonably Foreseeable or Non-NDRF) allowed people who faced years of suffering to have access to MAiD. These more complex criteria included the requirement of one witness (who could be a healthcare professional or worker), a 90-day minimum waiting period, two assessors (one of whom must consult or be a specialist in the relevant condition), and the required offer of counselling, palliative and/or support services. Statistics showed that this path was followed mostly by patients with neurological and other incapacitating conditions, rather than cancer. Since MAiD has started in Canada, a total of 30,000 people have had medically assisted death, but only 2.2% have been Track 2.
A key question that Dr. Jean considered was why people seek MAiD and, somewhat surprisingly, pain was not the main reason. The perceived nature of their suffering was most significantly their loss of ability to engage in meaningful activities or to perform the activities of daily living. They could not do what they wanted to do as part of a normal life. Inadequate pain control, loss of dignity and control over bodily functions and mental suffering were also significant.
Dr. Marmoreo talked about the legacy of COVID, in particular its devastating effects on mental health and long-term care facilities. The legacy of isolation, incapacity, illness and loneliness with the prospect of possible dementia has led many elders to ask hard questions about the future of their care. Elders want aging in place, connection, contribution, care, safety of housing, pleasure and mastery over the end of life. Most do not want to end their lives in long-term care.
But what happens if dementia removes awareness and the ability to make decisions, including MAiD? Advanced requests do not exist at present but Quebec is considering a bill to address the issue, based on the concept of body autonomy as a charter right. Although Benelux countries have had such a provision for 12 years, this issue remains one of the most controversial in Canada.
Dr. Jean’s presentation sparked a lively discussion, which included
- the logistics of getting MAiD (especially when the patient is in a faith-based facility that will not allow it);
- the process and steps in initial assessment (a telephone number on a government website as a good start);
- why Quebec seems to be a leader in MAiD development; and
- the current split in the psychiatric profession over provision of MAiD for mental illness.
Dr. Jean’s warmth, calm humanity and care for the suffering of her patients were consistently apparent in her presentation. Her book, The Last Doctor: Lessons in Living from the Front Lines of Medical Assistance in Dying, was recently published and tells the end-of-life journey of some of her patients and the perspective she gained from assisting them. In addition, her website (www.dr-jean.com) and the Dying With Dignity website (www.dyingwithdignity.ca) provide a wealth of useful background information.
by Don Plumb