MedicalAssistanceinDying

RegulatoryPerspec6ve

AndréaFo6,LL.B,M.A.

CollegeofPhysiciansandSurgeonsofOntario

Overview

1.   Background

2.   CPSO’swork

3.   Prac6ce&ComplianceIssues

Disclosures

•  Nofinancialdisclosures

•  Iam•  HeadofPolicyatCPSO•  LeadonCPSOMAIDfile

•  IwasanaffiantinCPSOLi6ga6on

BackgroundTheSupremeCourtofCanadafoundthattheCriminalCodeprohibi6onuncons6tu6onalbecauseitpreventedpa6entsfromgeQngassistancetoendtheirlife.

1FederalGovernment13Provincial/Territorial

13MRAs

MRAsdevelopguidancebasedonCarterfor‘interimperiod’

InterimPeriod

Federallawinforce

MRAsreviseguidancebasedonFederallaw

MRAWork

MajorityofMRAshavearesourceonMAID→Reflectfederallaw

→Addressgaps/prac6ceissues:•  Guidingprinciples•  Interpreta6onofeligibilitycriteria•  Conscien6ousObjec6ons•  DrugProtocols&Prescribing•  RecordKeeping&documenta6on

Legalmandate:Regulatetheprofessiontoprotectandservethepublicinterest

Ontario

MinistryofHealthandLong-TermCare

Guidelines,CodeofEthics,StandardsonMAID

•  Setoutrequirementsoffederallegisla6on

•  Prac6ceissues•  Conscien6ousobjec6ons•  Prescribinganddrugsissues•  documenta6on

OntarioCollegeofPharmacists

CollegeofNursesofOntario

•  Drugcosts•  BillingCodes•  CareCoordina6on:informa6on,referrals

•  OntarioCollegeofFamilyPhysicians•  OntarioHospitalAssocia6on•  CanadianMedicalAssocia6on•  JointCentreforBioethics-UofTorontoge

CPSO’swork

MAIDpolicy

Prac6calDirec6on:ü  ProcessMapü  DrugProtocols

FillsGaps:ü  RecordKeepingü  Conscien?ousObjec?on:

Effec?vereferralobliga?on

Alignswith:ü  FederalLawü  Relevant

ProvincialLawsü  RelevantCPSO

policies

Step1:Pa6entInquiry

Step2:EligibilityAssessment(Clinician#1)

Step3:Pa6entRequest

Step4:Reminder-Pa6entcanrescind

Step5:Eligibilityconfirmed

(Clinician#2)

Step6:Reflec6onPeriod

Step7:Inform

Pharmacist

Step8:Confirmconsent&

ProvideMAID

Step9:Cer6fica6onofDeath

ProcessMap

Prescribing&DrugProtocols

•  Drugprotocols:Oregon,Quebec,Alberta•  OngatedpartofCPSOweb•  Resourcesforphysicians;nooneprotocolrecommended;prescribingasprofessionaldecision

•  Protocolsavailable:members’onlypage

•  Resources,noprotocolisrecommended

•  Prescribingdecisions=makerofprofessionaljudgement

Conscien6ousObjec6on:‘Effec1veReferral’

Referralcanbemadetoaphysician,nurseprac66oneroragency;

Physician,nurseprac66oneroragencymustbenon-objec6ng,accessibleandavailabletothepa6ent;Referralmustbemadeina6melymanner;pa6entmustnotsufferadverseoutcomeduetodelay

Objec6ngphysiciansdonothavetoprovideMAID;theydohavetoprovidean‘effec6vereferral’

Li6ga6on:June

2017

Addi6onalResources

www.cpso.on.ca

Prac6ce&ComplianceIssues

Public&PhysicianAdvisoryServices

•  Calls,queriesfromtheprofessionandpubliconMAID

•  Totalof681inquiriessinceApril2016

OfficeoftheChiefCoronerofOntario

•  Oversightandcompliancemonitoringrole

•  Trackingtrends,prac6ceissues

PPASMAIDInquiries(sinceApril12016)

44%Physicians

56%Public

681Inquiriestotal

PhysicianInquiries:TopIssues

0 20 40 60 80 100 120 140 160 180

Records/Documenta6on

DrugProtocols

Conscien6ousObjec6on

ReferralSupport

PhysicianTraining/Scope

Policy/LawInterpreta6on 32

19

38

161

20

16

PublicInquiries:TopIssues

0 20 40 60 80 100 120

Opposi6ontoBill84

Effec6veReferral-Opposi6on

Informa6onforFamilyMember

SeekingWillingProvider

LekerstoGovernment

Opposi6ontoMAID 51

108

25

11

58

94

•  Documenta6on:lackof/insufficientdocumenta?on

•  Witnesses:notindependent;notcontemporaneous

•  Reflec6onPeriod:devia?onforalterna?vereasons

•  DrugProtocols:lackofawarenessofprotocols

•  Coordina6on&Communica6on:amongstproviders

Coroner’sOffice:KeyIssuesinPrac6ce

→Understandingandapplyinglawandpolicy

Li6ga6on:Conscien6ousObjec6onFocus:‘Effec?veReferral’&s.2(a)ands.15(1)

Par6es:Date:June2017;decisiononreserve

SuperiorCourtofJus6ce(DivisionalCourt)

•  Chris6anMedical&DentalSocietyofCanada

•  CdnFedera6onofCatholicPhysicians’Socie6es

•  CanadianPhysiciansforLife•  5individualphysicians(CPSO

members)

•  CPSO

Intervenors

TwoCPSOpolicies:MAIDandHumanRights

Li6ga6on:snapshot

Procedural•  DoestheCharterapplytotheCPSO?

•  Arethepolicies‘ultravires’CPSOjurisdic6on?

•  WhatStandardofReviewisapplicable?

Substan6ve•  Does‘effec6vereferral’

requirementviolatephysicianCharterrights?[s.2(a)ands.15(1)]

•  Ifso,isitsavedbys.1?

•  Is‘effec6vereferral’equivalenttoperformingobjec6onableprocedure?

•  DoCPSOpoliciesplacephysiciansinjeopardy:adheretobeliefsorriskregulatorysanc6on?

Someques6onsadvanced…

•  Applica6on&Interpreta6onofEligibilityCriteria:‘advanceddeclineincapability’•‘reasonablyforeseeabledeath’

•  AccesstoCare:ruralcentres,willingproviders

•  Billing&Fees•  OralDrugs:access&efficacy

•  DataCollec6on&Oversight

•  MatureMinors,MentalIllness,AdvanceRequests

OutstandingIssuesCareCoordina6onService

www.cpso.on.ca