New MAiD model practice standard: Advice to practitioners on many topics including suicidality

Health Canada has released a new model practice standard for Medical Assistance in Dying (MAiD) that includes how to care for people with mental illness as the sole underlying medical condition. The standard was created by a task group of experts who also provided advice to the profession, which outlines in more detail how the terms used in MAiD legislation should be interpreted at the bedside. The idea is that provincial and territorial physician and nurse medical regulators can adopt—or adapt—the model practice standard in time for when people with mental illness as the sole underlying medical condition become eligible for MAiD on March 17, 2024. The standard provides a “clear articulation of the process and things to consider for patients whose death is not reasonably foreseeable,” said Dr. Gus Grant, registrar of the College of Physicians and Surgeons of Nova Scotia. Dr. Grant served as a member of the task force representing the Federation of Medical Regulators of Canada (FMRC). “These documents put profession in a state of readiness,” he said, adding that the public and physicians will see that there is a “logical clear progression” of requirements before providing MAiD. The model practice standard was built on existing practice standards from physician and nurse medical regulators, “so the resources we produced could easily be adopted or adapted to suit them,” said Dr. Mona Gupta, chair of the task force and also the federally appointed expert panel on MAiD and mental illness, as well as a psychiatrist and assistant professor at the University of Montreal. The model practice standard underwent a rapid review to which all the physician and nurse provincial and territorial medical regulators, ministries of health, medical professional associations and other experts were invited to participate, Dr. Gupta said. There are a number of new sections in the practice standard, such as how MAiD assessors and providers should address suicidality, assess if the request was made voluntarily and when it is appropriate to raise the subject of MAiD with patients. While the advice to the profession touches on the clinical issues, neither the advice to the profession nor the practice standard are a replacement for clinical practice guidelines or clinical training, Dr. Gupta said. The specifics of clinical situations, such as knowing how to evaluate if a person is in crisis, will be further addressed with training and clinical professional development, she said. Wording The task force paid rigorous attention to the wording of the model standard, Dr. Grant said. This means regulators can respond to complaints appropriately, and the language “is really clear on what the member was supposed to have done, and it is as straightforward as it can be to determine whether the member had adhered to what was in the standard,” Dr. Gupta said. The task force was able to further define some of the terms included in legislation surrounding MAiD, such as “incurability,” “irreversibility of decline,” “suffering” and “serious consideration,” Dr. Gupta said. “We hope that, having elaborated on these terms, that this will be useful to clinicians in the front line.” Dr. Gupta said. For example, a “grievous and irremediable medical condition” requires that three criteria are met: that the patient’s illness is serious and incurable that they are in an advanced state of irreversible decline in capability that there is an enduring and intolerable suffering that cannot be relieved by means acceptable to the person. The advice to the profession provides further information on how to assess if the condition is “incurable” and determine if there are no reasonable treatments remaining. It suggests that the clinician and the patient need to work together to review potential treatments to decide what treatments can be considered reasonable, given the patient’s state of health and goals of care. The advice to the profession suggests there is no specific number of treatment trials a person has to undergo before their condition is considered as incurable. However, the advice states that “a capable person cannot refuse all or most interventions and automatically render themselves incurable for the purposes of accessing MAiD.” Relieve suffering Under the new MAiD legislation, those for whom death is not reasonably foreseeable must be told of the “means to relieve suffering.” This is important because of widespread concern that people may request MAiD because of a lack of housing or disability supports. The advice to the profession elaborates on what the legislation requires, which includes providing information on mental health or disability support services, palliative care, housing services and income support. The person requesting MAiD has to give “serious consideration” to the means available. The advice to the profession explains that the person must consider carefully and without impulse. “Serious consideration includes a genuine openness to the means available to relieve suffering,” it states. Clinicians must be aware of if a person is more vulnerable to systemic barriers or biases, including an inability to access appropriate resources, the advice to the profession notes. Read: Feds launch new Model Practice Standard for MAiD Suicide With people with mental illness becoming eligible for MAiD, the model practice standard has a section dealing with suicidality. It notes the assessor must ensure that the request for MAiD must be “rationally considered during a period of stability, and not during a period of crisis,” and that the assessor must consider referring patients to suicide prevention supports for those who are ineligible for MAiD. The advice to the profession goes on to address suicide in more detail. For example, a person with a past history of suicidality is still capable of consenting to MAiD, because the capacity to consent is assessed with regards to the current request for MAiD. The advice to the profession addresses, but does not resolve, the debate on whether to consider a request for MAiD as a form of suicidal ideation. To illustrate how to approach a request from a person whose death is not reasonably foreseeable, the task force provides the comparative example of a person who chooses to stop renal dialysis, and how clinicians handle that request, including sometimes obtaining a psychiatric consultation. Read: What physician witnesses had to say at the special joint committee examining MAiD Interpersonal dynamics The model practice standard has a section on challenging interpersonal dynamics. How exactly to deal with these challenging dynamics, be it threatening behaviour or another situation, is left open to allow for flexibility depending on the specifics of the situation. “It is more to alert physicians and nurses to the possibility of this, and to let them know that they need to address this situation in some way,” Dr. Gupta said. There is also strict wording and advice on ensuring that the person requesting MAID is doing so voluntarily, without undue influence, including the influence of past abusive relationships. The advice to the profession notes that a request may not be voluntary one time, but may be voluntary at a later time. Consultations The task force included when assessors should consult with other clinicians. It notes that a clinical practitioner with expertise does not have to be a Royal College-certified specialist. “That’s a really important point. There are many regions where patients have difficulty assessing care,” and might not be receiving care from a specialist, Dr. Grant said. When to initiate the discussion The thorny issue of when to introduce MAiD into a physician-patient discussion is also addressed in the model practice standard and advice to the profession. Some people may not be aware MAID is an option, but raising the topic may communicate the incorrect message to the patient. “If a practitioner has determined that MAiD is consistent with a patient's values and goals of care and has good reason to believe that the person might be eligible to receive MAiD, the practitioner must inform the patient about MAiD,” the advice to the profession states, adding that the timing can be decided using profession judgement. The Canadian Association of MAiD Assessors and Providers (CAMAP) has resources on how to introduce MAiD as an option. While the federal Special Joint Committee on Medical Assistance in Dying examined the question of advance directives or requests for MAiD, these are not yet part of the current MAiD regime and are not reflected in the current model practice standards. Quebec’s National Assembly is currently discussing this under Bill 11. The model practice standards and the advice to the profession are available from Health Canada on Canada.ca. Read: Quebec tables legislation to allow advance requests for medical assistance in dying

New MAiD model practice standard: Advice to practitioners on many topics including suicidality

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