Social Policy

Physician assisted dying: Offering a choice means making tough decisions

By June, every provincial and territorial government across the country will be tasked with building legislation around the federal government’s own laws allowing nationwide access to physician assisted dying (PAD). As of Feb. 6, access to PAD is already mandated across the country, with court-approval.

Chances are, the demand won’t be too high in the North.

Robert Zimmerman, chair of the Yukon Medical Council, says according to figures developed in Oregon – the first U.S. state to legalize the practice – in a population of 4 million people, about 160 will seek medical support in ending their life. In the Yukon, Zimmerman says this translates into probably one or two people out of the population of 38,000, and even fewer in the Northwest Territories and Nunavut.

Still, all provinces and territories are being forced to prepare for the coming legislation. So what sort of planning and engagement is currently underway toward building a framework around physician assisted dying?

Planning ahead

In Yukon, an internal advisory/working group is focusing on implementation of PAD, according to deputy health minister Paddy Meade.

The group includes the department of health, the hospital, health care providers, the Council of Yukon First Nations, the Yukon Medical Council, and the department of community services.

Meade said the group is focusing on how PAD would be implemented in the Yukon health system in particular.

In the NWT, the GNWT sought public and stakeholder feedback on the issue until Feb. 15, and now has a provincial and territorial expert advisory group report on PAD accessible on the health department website. The report has been sent out to Aboriginal governments, medical associations, nursing organizations, and other involved groups, according to Health Minister Glen Abernethy, who said the department would be working closely with those groups to put together interim guidelines around PAD that can go live and be available to residents when the federal legislation passes in June.

“We honestly don’t know what the federal legislation is going to say at this point.”

Meanwhile, over in Nunavut: “In anticipation of the legislation being finalized, the Department of Health, and Government of Nunavut, has established an internal advisory committee to review the new law once released by the Federal Government,” said Nunavut deputy health minister Colleen Stockley in an email response to Northern Public Affairs. “The committee will develop a process of consultation and feedback with key external stakeholders within Nunavut. No other information is available on an anticipated timeline.”

The fact is, until the federal government lays out its legislation, no finalized decisions can be made on the part of the territories.

We honestly don’t know what the federal legislation is going to say at this point, we don’t know what types of restrictions and that sort of thing,” Abernethy said.

The federal government has put together a special committee to create a report that will advise its own legislation on PAD, and Abernethy said it’s likely the provinces and territories will be privy to that report.

That will help us move forward and inform us, but until that legislation passes, we won’t know the exact words that are in it.”

Ensuring competency

While territorial legislators await their federal lead, the pan-territorial report makes some recommendations toward the major concerns around PAD: competency and qualification.

The panel suggests two physicians be required to assess a patient’s competency, using existing measurement systems:

“Where there is limited physician supply, provinces and territories should enable virtual physician assessments and visits using telemedicine services (or other video-based consultations), or if necessary, transport reviewing physicians to the patient for the second assessment…For decisions related to competency, existing mechanisms in the health care/legal system by which patients can appeal competency decisions should be used.”

The panel also recommends that a patient’s access to PAD not be impacted by age limits, but by their competency and the severity of their condition:

“‘Grievous and irremediable medical condition’ should be defined as a very severe or serious illness, disease or disability that cannot be alleviated by any means acceptable to the patient. Specific medical conditions that qualify as ‘grievous and irremediable’ should not be delineated in legislation or regulation.”

“We are awaiting the federal government response that will hopefully address such issues related to vulnerable people,” Meade said of the Yukon, adding that there is strong consideration for a patient’s capacity to make this end-of-life decision when PAD is implemented.

Concerns about consultation

Still, there remain certain concerns about the implementation of such legislation in the North.

When the legislation goes forward in the NWT, Abernethy said it will need to be both comprehensive and respectful of differing cultures and opinions. While not forcing practitioners to act against their own beliefs, the legislation also has to provide fair access to all residents.

The pan-territorial panel report recommends that, while practitioners and faith-based facilities should not be forced to practice PAD, they should be required to present it as an option to patients and facilitate their transportation to another service provider or facility to allow access.

While the legislators and the expert panel report have been careful to highlight this point, Francois Paulette, chair of the Stanton Territorial Elders Wellness Council in the NWT, says this offers little in the way of relieving his concerns over Aboriginal engagement.

“They’re not dealing with a fiscal problem here, they’re dealing with fundamental values of life and death.”

Indigenous nations, we are a nation of people with a very certain history, with a very distinct spiritual belief system. In many ways, there are some Canadian laws that do not apply to us,” Paulette said.

We have our own way, we have traditional systems, spiritual systems that are in place with how to deal with living and dying and birthing, based on our spiritual laws that have been laid down.”

His recommendation is a roundtable of Indigenous people, particularly elders and leaders, to set out their own principles and interests in dealing with this law. It cannot be assumed, he says, that Indigenous people are simply a part of the same system that the government creates.

We’re not dealing with programs and services; we’re dealing with human values, human rights, treaty rights, and that falls on us – it doesn’t fall on the GNWT.”

The Inuit Tapiriit Kanatami – which facilitates the Inuit Knowledge Centre for research toward Arctic science and policy – has not yet engaged with the government on the issue of PAD, nor has it been a topic of focus for the organization. In the future, a representative of the organization said engagement is certainly possible.

The Council of Yukon First Nations was a part of the territorial advisory working group on PAD, but a representative could not be reached for comment.

The sooner roundtable discussions among Indigenous people begin, the better, says Paulette, but there is no sense in the government rushing legislation around such a significant issue.

They’re not dealing with a fiscal problem here, they’re dealing with fundamental values of life and death,” he says. “The government has a fiduciary obligation to First Nations; they have to talk to us.”

Unique realities of the North

With PAD being legislated across the country, there are ways in which the North is uniquely impacted by this legislation.

“The North, as well as several provinces, must deal with access and equity while challenged by remote delivery,” Meade said of the Yukon. The role of health care providers, remote communities, and other geographical challenges are being considered in the Yukon’s legislation, similar to the northern areas of the provinces.

“In the Northwest Territories, we have some unique realities,” Abernethy agreed. Fifty-three per cent of our population is Aboriginal, we have many communities that are small, isolated, rural, remote, have limited access. Only 17 of the 33 communities have roads, 14 are accessible by winter road, and four only by airplane or boat, and many health centres in these communities don’t have physicians on staff.”

“The North, as well as several provinces, must deal with access and equity while challenged by remote delivery.”

He said involving nurses’ associations in the development of this legislation is important, as they may be the healthcare providers acting on requests.

The expert panel recommends that a request be made to the federal government to allow for health-care providers outside of physicians to administer PAD, and that it be made available wherever the patient lives, whether it be a hospital, long-term care facility, or home – with the exception of facilities where there is an objection to the practice:

“Provinces and territories should request that the federal government amend the Criminal Code to allow the provision of physician-assisted dying by a regulated health care professional (registered nurse or, if applicable, physician assistant) acting under the direction of a physician, or a nurse practitioner. Provinces and territories should in turn ensure that no regulatory barriers exist that would prevent these health care professionals from providing physician-assisted dying.”

As the new legislation comes into practice, the panel has also recommended further studies. The provinces and territories have been asked to create an inventory of patient information on the demographics and reasons for patients requesting physician-assisted dying.◉

Photo credit: istockphoto/XiXinXing

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