Are physicians ready for the MAiD expansion to include mental illness?

A growing group of psychiatrists and other physicians are calling to delay the March 17, 2023 implementation of the law that allows access to medical assistance in dying (MAiD) to people with mental illness as their sole underlying condition. Yet medical regulators and MAiD assessors and providers have a duty to be ready by the original date, others say. The most recent amendment to the Criminal Code to allow MAiD, proposed as Bill C-7, was passed on March 17, 2021 but included a two-year-long pause on allowing MAiD to people whose sole underlying medical condition is mental illness. This pause was to give experts time to review and recommend protocols, safeguards and guidance. The Association of Chairs of Psychiatry of Canada (ACPC) issued a statement on Dec. 1, 2022 calling on the government to delay the expansion of MAiD to patients whose sole underlying condition is mental disorder, sometimes called MAiD-SUMD. The association issued the statement “because they believe that, at this point in time, our health are system, our academic health centers and our healthcare providers across the country are not sufficiently prepared, informed and/or trained for the implementation of MAiD-SUMD,” explained Dr. Claudio Soares, head of the department of psychiatry at Queen’s University School of Medicine. “While we acknowledged that a significant amount of work has been done to establish standards and guidelines for MAiD-SUMD, there are still important questions to be answered; for that, we still need a greater awareness about MAiD and a broader engagement of our medical community.” One of the challenges that still needs to be addressed is a consensus on the definition of irremediability for mental disorders, Dr. Soares told the Medical Post. MAiD can only be provided in cases where the medical condition is grievous and irremediable. The government-appointed Expert Panel on MAiD and Mental Illness provided a list of recommendations on May 13, 2022. The recommendations address the question of irremediability, and included: that MAiD assessors must determine incurability and irreversibility on a case-by-case basis with reference to the patients’ treatment history. that those requesting MAiD and those assessing MAiD eligibility must agree that the person is in “an advanced state of irreversible decline in capability” that causes enduring and intolerable suffering that those requesting MAiD must have access to the fullest possible range of social supports (including housing and income support) that could help reduce suffering that assessors should be psychiatrists with expertise in the condition independent from the treatment team Read: Comments from Quebec College of Physicians about possible expansion of MAiD alarm disability advocates Standards of practice A Health Canada-led task force is developing model standards to help with the implementation of the recommendations of the expert panel. The model standards are based on the recommendations from the expert panel. They will include a suggested definition of irreversibility. They will be ready in time, Dr. Douglas Grant told the Medical Post. Dr. Grant is the registrar of the College of Physicians and Surgeons of Nova Scotia and serves as the Federation of Medical Regulatory Authorities of Canada (FMRAC)’s representative on the Health Canada-led task force. “We can’t forget that there are patients suffering who are entitled to this service, and that the courts have said are entitled to this service, so we have a duty and a responsibility to be ready and we will be ready,” he said. Dr. Grant was the president of FMRAC when MAiD was first made legal in Canada. He notes that the concerns surrounding the timing of the expansion of MAiD are similar to those made in 2016. “There have been a number of voices out there saying, 'Lets slow down, we’re not ready.' Those same sentiments were expressed in 2015 and 2016. And the regulators were ready and the profession was ready, and the delivery of MAiD began successfully in 2016,” he said. The model standards will hopefully “assist, inform, and facilitate” provincial and territorial medical regulators when developing changes to practice standards to accommodate the provision of MAiD to those whose sole underlying medical condition is a mental disorder. It will develop language that will help practitioners and regulators understand their responsibilities and what they need to consider under the law. Training The Association of Chairs of Psychiatry of Canada are also asking for a delay because psychiatrists and other healthcare professionals need appropriate training to assess patients for MAiD in cases where the sole underlying condition is mental disorder. The training has to include educational tools. The federal government is providing $3.3 million to the Canadian Association of MAiD Providers and Assessors (CAMAP) to develop medical education modules for healthcare professionals. In a statement in October, federal health minister Jean-Yves Duclos said the modules will be launched in early 2023. CAMAP is currently recruiting healthcare professionals to participate in a pilot evaluation of education modules about MAiD. “By March 2023, we expect there will be practice standards and training modules in place which will serve to provide clarity for practitioners involved in assessing challenging MAiD requests from persons where concerns outlined by the Panel arise, including but not limited to requests from persons with a mental disorder,” Duclos said. Read: Non-profit aiming to provide homey atmosphere for MAiD patients seeks permanent location Access to mental health and addictions care The ACPC is also calling for greater access to mental health and addictions care when the expansion of MAiD is allowed by law. It notes that the COVID-19 pandemic impacted Canada’s mental health system and many services have yet to recover due to staffing shortages. The association also wants to ensure strong public awareness and education about suicide prevention. The federal government is investing $5 billion over 10 years through agreements with the provinces and territories to improve access to mental health and addiction services, Duclos said in his Oct. 20 statement. He was responding to an interim report from the joint parliamentary committee examining the provisions in Canada’s Criminal Code to permit MAiD, and how those provisions are applied, including MAiD when mental disorder is the sole underlying medical condition. The association didn’t propose a specific timeline for adopting MAiD for cases where mental disorder is the sole underlying cause. “We are just asking to slow down the implementation so we can properly address these issues,” Dr. Soares said. A petition is being circulated by the Society of Canadian Psychiatry, a group of concerned psychiatrists led by Dr. Sonu Gaind of the University of Toronto and Dr. John Maher, president of the Ontario Association of Assertive Community Treatment (ACT) teams and Flexible Assertive Community Treatment (FACT) teams. The petition is asking for a delay in implementing the law permitting access to MAiD to people whose sole underlying condition is mental illness. The delay is to allow for more consultation and review of the safety and risks, the group’s website reads. Both Dr. Gaind and Dr. Maher spoke as witnesses as part of the joint parliamentary committee meetings. The committee stopped hearing from witnesses on Nov. 27, 2022 and will file their final report in 2023. The Expert Panel on MAiD and Mental Illness also recommended that provincial and territorial medical regulatory bodies must consult with First Nations, Métis and Inuit peoples with respect to MAiD for people where mental health is the sole underlying medical condition. “The regulators and the professions will be ready to deliver this legal service in March,” Dr. Grant said. “Will we be ready? Absolutely.” Any discussion about the March 17, 2023 expansion of MAiD “needs to put the patient first,” Dr. Grant told the Medical Post. “There are suffering patients who are entitled to this service and will soon be able to obtain it legally.”

Are physicians ready for the MAiD expansion to include mental illness?

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