National Assembly of Québec Report of the Select Committee on the Evolution of the Act respecting end-of-life care

List of Recommendations and Observations

Recommendations

Recommendation 1

The Committee recommends that a person of full age and capacity be permitted to make an advance request for medical aid in dying following a diagnosis of a serious and incurable illness leading to incapacity.

Recommendation 2

The Committee recommends that when a person makes an advance request for medical aid in dying, the physician ensure:

• a) The free nature of the request by verifying, among other things, that it is not the result of external pressure;
• b) The informed nature of the request, in particular by ensuring that the person has fully understood the nature of his or her diagnosis, by informing the person of the foreseeable course and prognosis of the disease, and of the possible therapeutic options and their consequences.

Recommendation 3

The Committee recommends that the advance request for medical aid in dying be entered on a form intended solely for that purpose; that it be completed and signed before a physician; that it be countersigned by two witnesses or made in notarial form.

Recommendation 4

The Committee recommends that the person clearly identify the manifestations of his or her health condition that should give rise to the advance request.

Recommendation 5

The Committee recommends that the advance request remain valid unless the person indicates otherwise; that it may be amended as long as the person is capable of doing so.

Recommendation 6

The Committee recommends that advance requests for medical aid in dying be recorded in the Advance Medical Directives Register.

Recommendation 7

The Committee recommends that a reference to an advance request for medical aid in dying be indicated on the back of the health insurance card.

Recommendation 8

• a) The Committee recommends that the person designate on the form a trusted third party responsible for making known his or her advance request for medical aid in dying and for advocating on his or her behalf for the processing of the request at the appropriate moment; that the trusted third party consent in writing to the role assigned to him or her;

• b) The Committee recommends that, in the absence of or inability to act of a designated trusted third party, the responsibility to protect the patient's wishes and to act be assumed by a member of the health care team.

Recommendation 9

The Committee recommends that when the trusted third party files the application on the advance request, the physician review both the application and the advance request, take them into consideration, and act on them without delay.

Recommendation 10

The Committee recommends that before administering medical aid in dying, the physician must

1. Be of the opinion that the person meets all of the following criteria:
• a) the person is an insured person within the meaning of the Health Insurance Act (chapter A-29);
• b) the person suffers from a serious and incurable illness;
• c) the person is in an advanced state of irreversible decline in capability;
• d) the person experiences constant and unbearable physical or psychological suffering, including existential suffering, which cannot be relieved in a manner deemed tolerable. This suffering is observed and validated by the physician.
2. Confer with members of the care team who are in regular contact with the person making the request, if applicable;
3. Obtain the opinion of a second physician confirming compliance with the criteria. The physician consulted must be independent of both the patient requesting medical aid in dying and the physician seeking the second medical opinion. The physician consulted must consult the patient’s record, examine the patient and provide the opinion in writing.

Recommendation 11

The Committee recommends that access to medical aid in dying not be extended to persons whose only medical condition is a mental disorder; that, to this end, section 26 of the Act respecting end-of-life care be amended.

Observations

The Committee suggests:

• That the existence of advance medical directives be indicated on the back of the health insurance card.
• That the application to initiate the processing of the advance request be made in writing.
• That it be possible to attach a complementary video to the application, but that the written request take precedence.
• That the physician discuss with the patient the medical advances related to his or her illness.
• That specialized nurse practitioners be allowed to administer medical aid in dying.
• That the government conduct an awareness campaign on the possible use of advance medical directives.
• That a reminder be given of the importance of systematically consulting the Advance Medical Directives Register.