AMAD Committee Report

Special Joint Committee on Medical Assistance in Dying: Supplementary Opinion

This Supplementary Opinion was prepared by four independent senators who serve on the Special Joint Committee on Medical Assistance in Dying (the “Committee”): the Honourable Pierre J. Dalphond (Quebec – De Lorimier) (PSG), the Honourable Marie-Françoise Mégie (Quebec – Rougemont) (ISG), the Honourable Stanley Kutcher (Nova Scotia) (ISG) and the Honourable Pamela Wallin (Saskatchewan) (CSG).

The Committee’s report summarizes views, concerns and opinions expressed by individuals and groups who contributed to its work. We are grateful to them. The report also contains 23 recommendations reflecting considerable consensus amongst the members of the Committee, and we urge the Government of Canada to act upon them.

The following supplementary information is meant to help readers identify some publicly available information related to issues addressed during the Committee’s study.

I.     HEALTH CANADA THIRD ANNUAL REPORT ON MEDICAL ASSISTANCE IN DYING IN CANADA 2021

Excerpts from Third Annual Report on Medical Assistance in Dying 2021

Highlights

The Third Federal Annual Report on Medical Assistance in Dying presents data for the 2021 calendar year, using data collected under the Regulations for the Monitoring of Medical Assistance in Dying. It builds upon the First and Second Annual Reports on Medical Assistance in Dying. With three full years of data collection now complete, three-year trends provide even greater insight into the picture of medical assistance in dying (MAID) in Canada.

The data is based on reports from medical and nurse practitioners and pharmacists on written requests for MAID and MAID provisions across Canada for the 2021 calendar year. [...]

Growth in the number of medically assisted deaths in Canada continues in 2021

• In 2021, there were 10,064 MAID provisions reported in Canada, accounting for 3.3% of all deaths in Canada.

[…]

Profile of MAID recipients

• In 2021, across Canada, a slightly larger proportion of men (52.3%) than women (47.7%) received MAID. This result is consistent with 2020 (51.9% men vs 48.1% of women) and 2019 (50.9% men vs 49.1% women).
• The average age at the time MAID was provided in 2021 was 76.3 years, slightly higher than the averages in 2019 and 2020 (75.2 and 75.3 respectively). The average age of women during 2021 was 77.0, compared to men at 75.6.
• Cancer (65.6%) is the most commonly cited underlying medical condition in the majority of MAID provisions, during 2021, slightly down from 69.1% in 2020. This is followed by cardiovascular conditions (18.7%), chronic respiratory conditions (12.4%), and neurological conditions (12.4%). Three-quarters of MAID recipients had one main condition, while one-quarter had two or more main underlying medical conditions.
• In 2021, 2.2% of the total number of MAID provisions (219 individuals), were individuals whose natural deaths were not reasonably foreseeable (non-RFND) (in Quebec since 2019 and the rest of Canada after the passage of the new legislation on March 17, 2021). The most commonly cited underlying medical condition for this population was neurological (45.7%), followed by other condition (37.9%), and multiple comorbidities (21.0%). The average age of individuals receiving MAID who were non-RFND was 70.1.

The majority of MAID recipients received palliative care and disability support services

• During 2021, the majority of MAID recipients (80.7%) received palliative care. This compares similarly to 2019 and 2020 (82.1% and 82.8% respectively). Of the MAID recipients who did not receive palliative care, 88.0% had access to these services if they required them.
• In 2021, 43.0% of individuals who received MAID required disability support services. Of these, the majority, 87.4%, received disability support services. These results are similar to 2019 and 2020 findings.
• The use of palliative care and disability support services is similar amongst all main conditions except for neurological conditions where the use of palliative care is lower (56.0%) and the requirement for disability support services is higher (66.8%)

Nature of suffering among MAID recipients

• The most commonly cited intolerable physical or psychological suffering reported by individuals receiving MAID in 2021 was the loss of ability to engage in meaningful activities (86.3%), followed closely by the loss of ability to perform activities of daily living (83.4%).

[…]

The total number of practitioners providing MAID continues to grow, and primary care physicians remain as the principal MAID providers

• The total number of unique practitioners providing MAID increased to 1,577 in 2021, up 17.2% from 1,345 in 2020. Similar to 2020, 94.4% of all practitioners administering MAID were physicians, while 5.6% were nurse practitioners. Physicians provided 91.6% of MAID procedures during 2021, while nurse practitioners took on an increasing share, performing 8.4% of MAID provisions.
• Family physicians continue to provide the majority of MAID provisions (68.2%), consistent with 2019 and 2020 results.

Private residences continue to be the primary setting for the administration of MAID in Canada

• In 2021, 44.2% of MAID provisions took place in private residences, continuing to be the primary setting for the administration of MAID in Canada. […] The remainder of 2021 MAID provisions took place in hospitals (28.6%), palliative care facilities (19.6%), residential care facilities (6.1%), and other settings (1.5%). These levels are similar with 2020 results.
• The Atlantic provinces had a higher proportion than other jurisdictions of MAID provisions for individuals living in rural areas, ranging from 42.1% in Nova Scotia to 46.2% in Prince Edward Island. By contrast, Alberta (84.1%), British Columbia (83.6%), Ontario (81.6%), Manitoba (80.7%), and Québec (79.1%) had the highest proportion of MAID recipients living in urban areas. This is consistent with 2020 and roughly representative of each jurisdiction’s general pattern of population distribution.

Requests not resulting in a medically assisted death

• There were 12,286 written requests for MAID in 2021.This represents an increase of 27.7% over the number of written requests in 2020. The majority of written requests (9,950 or 81.0%) resulted in the administration of MAID.
• The remaining 2,336 requests (19.0%) resulted in an outcome other than MAID: 231 individuals withdrew their request (1.9% of written requests); 487 individuals were deemed ineligible (4.0% of written requests); and 1,618 individuals died prior to receiving MAID (13.2% of written requests).
• The main reasons for the withdrawal of a MAID request was the individual changed their mind (62.3%) or that palliative care was sufficient (38.5%). For 12.1% of withdrawals (28 individuals), withdrawal occurred just prior to the MAID procedure when asked to provide their final consent.
• In 2021, 487 individuals were deemed ineligible for MAID, representing 4.0% of all written requests. […] The most common reason for a determination of ineligibility was due to the individual not being capable of making decisions with respect to their health (33.1%)., consistent with 2020 results.

[…]

II.   2021-2022 ANNUAL REPORT OF THE COMMISSION SUR LES SOINS DE FIN DE VIE

Excerpts from the Annual Report on Activities prepared by the Commission sur les soins de fin de vie tabled in the National Assembly of Quebec on December 9, 2022.

SUMMARY

The mandate of the Commission sur les soins de fin de vie (hereinafter referred to as the “Commission”) is to examine all matters relating to end-of-life care and to oversee the application of specific requirements relating to medical aid in dying. This annual report highlights the Commission’s activities and achievements and presents data on palliative and end-of-life care made available to the Commission for the period from April 1, 2021 to March 31, 2022.

Medical Aid in Dying (MAID)

• The number of medically assisted deaths and the percentage of deaths involving MAID have been rising since the Act respecting end-of-life care (ARELC) went into effect.
• 3,663 individuals received MAID between April 1, 2021 and March 31, 2022 (5.1% of deaths). This amounts to a year-over-year increase of 51%, or 1,236 more medically assisted deaths.
• • Most individuals were 60 years of age or older (93%), suffering from cancer (66%), given a survival prognosis of 1 year or less (84%) and enduring irremediable physical and psychological suffering (95%).
  • They received MAID in a hospital centre (54%), at home (33%), in a residential and long-term care centre/CHSLD (8%) and in a palliative care hospice (5%).
  • On average, MAID is administered 26 days after the request is signed.
• Almost all cases of medically assisted deaths (over 99%) were administered in compliance with the requirements of the Act respecting end-of-life care.
• Almost two-thirds of formal requests for MAID were administered (68%).
• The main reasons given to explain why MAID was not administered following a formal request were the following: death occurred before completion of the assessment process or before administration of MAID (34%); individuals did not meet or no longer met the criteria for eligibility prescribed in the Act respecting end-of-life-care (22%) or the request was withdrawn (18%).
• 1,418 physicians participated in medically assisted deaths; this represents an increase of 26% versus 2020-2021 (85% were general practitioners and 15% were physician specialists).

Palliative/end-of-life care and continuous palliative sedation

• 58,846 individuals were receiving palliative/end-of-life care between April 1, 2021 and March 31, 2022. They benefitted from palliative/end-of-life care at home (44%), in a hospital centre (35%), in a residential or long-term care facility/CHSLD (13%) and in a palliative care hospice (8%).
• 1,838 individuals received continuous palliative sedation during the current period (2.6% of deaths).

Conclusion

The Commission notes that requests for MAID are increasing and that MAID has become an important subject of public debate in Quebec. Why does Quebec have more medically assisted deaths per million people when compared with Ontario, Canada and Belgium? The Commission would like to see this social debate continue and, when parliamentary business resumes in fall 2022, it would also welcome the tabling of a bill to ensure that an advance request for MAID can be completed by anyone who has been diagnosed with a serious and incurable neurocognitive disorder, in anticipation of incapacity to provide consent.

III. PUBLIC OPINION POLLS: SUPPORT FOR MEDICALLY-ASSISTED DYING IN CANADA

Excerpts from the 2023 Ipsos poll: Support for medically-assisted dying in Canada (MAID for mental disorders)

A strong majority (82%) of Canadians agree that with the appropriate safeguards in place, an adult with the capacity to provide informed consent should be able to seek an assessment for medical assistance in dying for a severe, treatment-resistant mental disorder for which they experience intolerable suffering. Support is comprised of 34% who strongly support and 48% who somewhat.

Younger Canadians tend to be more supportive of this policy: those between the ages of 18-34 (87%) exhibit stronger levels of agreement than those aged 35-54 (77%). Interestingly, those over the age of 55 (41%) are more likely to strongly agree than those between the ages of 18-34 (29%) and 35-54 (32%).

Moreover, Quebec residents (91%) are more like [sic] to agree that those suffering from solely a severe mental disorder can access the MAID assessment compared to residents in Alberta (76%), Ontario (78%) and Atlantic Canada (79%).

Excerpts from the 2022 Ipsos poll: Support for medically-assisted dying in Canada

Support for MAID and advance requests remain firm among Canadians, and the proportion of Canadians who support removing the “Reasonably Foreseeable” requirement from federal assisted-dying law has risen by 13-points over last year. Canadians are thus becoming more adamant about ensuring that patients have the right to choose end-of-life choices they desire. More specifically:

[…]       

• 85% support advance requests for those with a grievous and irremediable condition.

[…]

IV. FINAL REPORT OF THE EXPERT PANEL ON MAiD AND MENTAL ILLNESS

Final Report of the Expert Panel on MAiD and Mental Illness

Excerpts from the Government of Canada Website on the Expert Panel on MAiD and Mental Illness

Canada’s new medical assistance in dying (MAID) law came into force on March 17, 2021. The new law expanded eligibility to MAID to include individuals whose death is not reasonably foreseeable, while also amending other aspects of the law.

The new MAID legislation temporarily excludes, until March 17, 2023, eligibility for MAID for individuals with a mental illness as their sole underlying medical condition. The legislation includes an obligation for the Minister of Health and the Minister of Justice to initiate an independent expert review “respecting recommended protocols, guidance and safeguards to apply to requests for medical assistance in dying by persons who have a mental illness.”

The Expert Panel on MAID and Mental Illness was launched to undertake this review. A report containing the Panel's conclusions and recommendations was tabled in Parliament on May 13, 2022. The findings will assist the Government in developing its approach for safely providing access to MAID for persons with a mental illness. This work will also help ensure that practitioners are equipped to assess these requests in a safe and compassionate way based on rigorous clinical standards and safeguards that are applied consistently across the country.

V.   2019 SUPERIOR COURT OF QUEBEC DECISION IN TRUCHON C. PROCUREUR GÉNÉRAL DU CANADA

Excerpts from Truchon c. Procureur général du Canada, 2019 QCCS 3792 (CanLII)

4.      Conclusions on the Evidence

[466]    From the evidence as a whole, the Court concludes as follows:

1. Medical assistance in dying as practised in Canada is a strict and rigorous process that, in itself, displays no obvious weakness;
2. The physicians involved are able to assess the patients’ capacity to consent and identify signs of ambivalence, mental disorders affecting or likely to affect the decision-making process, or cases of coercion or abuse;
3. The vulnerability of a person requesting medical assistance in dying must be assessed exclusively on a case-by-case basis, according to the characteristics of the person and not based on a reference group of so-called “vulnerable persons”. Beyond the various factors of vulnerability that physicians are able to objectify or identify, the patient’s ability to understand and to consent is ultimately the decisive factor, in addition to the other legal criteria;
4. The physicians involved are able to distinguish a suicidal patient from a patient seeking medical assistance in dying. Moreover, there are important distinctions between suicide and medical assistance in dying with respect to both the characteristics of the people involved and the reasons that motivate them;
5. Neither the national data in Canada or Quebec nor the foreign data indicate any abuse, slippery slope, or even heightened risks for vulnerable people when imminent end of life is not an eligibility criterion for medical assistance in dying.

VI. 2020 SUPREME COURT OF CANADA DECISION IN ONTARIO (ATTORNEY GENERAL) V. G

Excerpts from Ontario (Attorney General) v. G 2020 SCC 38

[74]      […] The inclusion of any method of exempting and removing those found NCRMD [not criminally responsible on account of mental disorder] from the registry based on individualized assessment would be less impairing of their s. 15(1) rights and could actually increase the registry’s effectiveness by narrowing its application to individuals who pose a greater risk to the community.

[75]      […] Individual assessment does not need to perfectly predict risk — certainty cannot be the standard […]

[76]      I accordingly conclude that the Attorney General has not met his burden under s. 1 to demonstrate that the infringing measure is not minimally impairing of the right and therefore has not justified the s. 15(1) infringement.