You want to introduce fundamental change to a controversial practice during a pandemic? Bill C-7 An Act to amend the Criminal Code (medical assistance in dying) will become law while every healthcare organization in the country is swamped by the worst crisis in living memory.
My concern is implementation. C-7 may well be law within the next couple of months.
Bill C-7 is the Government’s response to Truchon v. Attorney General of Canada. It will:
- Repeal Criminal Code 241.2(2)(d) “their natural death has become reasonably foreseeable …”;
- Specify that persons whose sole underlying medical condition is a mental illness are not eligible for medical assistance in dying;
- Create two streams: one if natural death foreseeable (s.3) and one if natural death not foreseeable (s.3.1);
- Permit Medical Assistance in Dying (MAiD) to be provided to a person found eligible to receive it, whose natural death is reasonably foreseeable and who has lost the capacity to consent before MAiD is provided, on the basis of a prior agreement they entered into with the medical practitioner or nurse practitioner (Final Consent – waiver s.3.2); and
- Permit MAiD to be provided to a person who has lost the capacity to consent to it as a result of the self-administration of a substance that was provided to them under the provisions governing medical assistance in dying in order to cause their own death (Advance consent – self administration s.3.5).
The federal government was twice granted extensions to the original court deadline; those extensions expire Dec. 18. C-7 has passed third reading in the House. Down to the wire, the government has applied for an unprecedented third extension (to Feb. 26, 2021). It remains to be seen if it will be granted. Either way C-7, once passed, will rush to Royal Assent. Health care must live with the fait accompli.
- There is no time to rewrite MAiD procedures to address new provisions.
- No time for staff education. Organizations are operating with staff shortages due to COVID-19. Those remaining are fully engaged in patient care, with no staff to cover for educational
- No time for personal reflection. Healthcare professionals (HCPs) do not have time to decide if they are willing to participate under the new provisions. Particular sticking points for some: waiver of final consent, newly admitted patient requests for immediate administration of MAiD and requests by patients whose natural death is not reasonably foreseeable. I saw physicians who were seriously conflicted by their participation in MAiD under C-14; under C-7 we may see more.
- After nine months of COVID, HCPs are burning out, especially in long-term care. Some suffer from moral distress or moral injury from COVID. New and controversial MAiD provisions could be the straw that breaks some backs.
- We cannot assume that HCPs who previously participated in MAiD will continue to participate under C-7. Some may withdraw. Some may withdraw until they have time to review the changes. Some may be willing to participate only with patients whose natural death is foreseeable. Will we have sufficient providers?
- During the first wave, some hospitals suspended the provision of MAiD. Others made procedural changes (e.g., virtual witnessing of requests) or changes to medications. With all COVID metrics increasing, daunted by the complexities of C-7, more organizations may put their MAiD service on hold.
- Under C-7, HCPs (not assessors or providers) will be permitted to witness requests. Will organisations allow staff to do this?
Under ideal circumstances, the federal government would have delayed implementation of C-7 to give healthcare time to prepare. Without C-7, and if the third extension is not granted, the Truchon decision will take effect in Quebec. The rest of Canada will operate under the current criteria. The government, understandably, wants pan-Canadian criteria. Hence the rush.
Knowledgeable patients will be asking for MAiD on the basis of the new provisions. Some will argue this is their right. Healthcare needs to be ready.
- Healthcare organizations must free up a point person who:
- Becomes conversant with the legislation and recognizes its organizational impact;
- Navigates others through the new process;
- Addresses questions and issues when cases arise; and
- Educates staff.
- Healthcare organizations must ensure debriefs on all cases to address staff concerns. This may mitigate moral distress.
- Organizations should participate in a MAiD community of practice (MAiD CoP) to share learning, forms and tools.
- Organizations need MAiD providers. Support for providers at all levels will be critical to making this work.
- Organizations that choose not to provide MAiD (even temporarily) need to anticipate what they will do when patients ask for it. Will they call on their provincial Care Coordination Service? Transfer the patient to another organization?
The author is grateful for feedback from Sharon Reynolds, nurse educator, and Kieran Quinn, palliative care physician, both at Sinai Health. The author also thanks Barbara Mains for her editorial suggestions.
There are no conflicts of interest to declare.