Medical Assistance in Dying

Cases at Ross Memorial Hospital have doubled in three years. A local doctor and a doula share their insights.

By Aliyah Mansur

Whether they choose MAID or other palliative care, working with a patient at the end of their life is both challenging and rewarding for healthcare teams.

Since Medical Assistance in Dying (MAID) was legalized in Canada in 2016, there have been concerns about the rapidly growing number of people accessing the health service.

The fourth annual report for MAID in 2022 showed a 30 per cent increase in cases from the previous year. Even locally, cases of MAID at Ross Memorial Hospital (RMH) have more than doubled from 2021 to 2024 (with 13 cases in 2021-2022 and 33 cases in 2023-2024) and this does not account for MAID administered outside the hospital.

With no sign of plateau, it’s fair to wonder whether proper protections have been put in place to keep vulnerable populations safe and ensure no one is being coerced into this palliative care option. To get an idea of what happens when a patient chooses MAID, we spoke with a local doctor and end-of-life doula, both of whom have MAID experience.

Dr. Brent MacMillan, a clinician at RMH and MAID provider, says that although cases are climbing “many referred patients are found to be ineligible for MAID because they do not fit the strict eligibility criteria.” MAID patients who are eligible will fall into one of two tracks. For track one, the patient’s natural death must be reasonably foreseeable. For track two, the patient’s death is not foreseeable and requires “a full review of all treatment options and concerted efforts to relieve their suffering during a three-month treatment period,” MacMillan says.

In addition, an expert opinion regarding the state and prognosis of the patient’s illness is needed and the treatment and reassessment cycle continues for a minimum period of three months, only considering MAID as a last resort. Patients in both tracks must make the request for MAID of their own volition and have a “serious and incurable illness, disease or disability” at “an advanced state of irreversible decline in capability” resulting in “enduring and intolerable physical or psychological suffering that cannot be alleviated” (this still excludes mental illness, until an expected review in 2027.)

Other criteria include: the patient must be 18 years of age or older, eligible for publicly funded health care services and give their informed consent (informed consent requires that the health care provider inform the patient of all the risks, benefits, and alternatives of a treatment or medical intervention they are considering.)

To become a MAID provider, physicians and nurse practitioners (the only clinicians allowed to become MAID providers) are highly recommended to take a 27-hour training program through Canadian MAID Curriculum and additional policy and legal requirements for clinicians has been put in place by the College of Physicians and Surgeons of Ontario. The Canadian Association of MAID Assessors and Providers organization offers further support for clinicians to interact with each other, especially for challenging cases that may benefit from a variety of clinical perspectives.

MacMillan, the clinician at RMH, became a MAID provider because, he says, “it is important for patient autonomy and dignity” and that patients should have “power at the time of their dying with an emphasis on quality of life… not quantity.”

Working in Kawartha Lakes as an end-of-life doula, Desiree Lodge describes her role as “the connecting link between the client, their family and caregivers and their medical team.” Similar to the doctor, she helps to ensure patients’ wishes are met “and (that) they die with the dignity they deserve.” Lodge became a doula for end-of-life after personal experiences with caring for aging and ill parents, where she says, “there was a gap between what care was provided by the medical field and hospice.” Though the doula does not provide MAID herself, she does offer additional support for patients who have chosen MAID and says the MAID context “doesn’t differ much from other end of life care we provide.”

Whether they choose MAID or other palliative care, working with a patient at the end of their life is both challenging and rewarding for healthcare teams. But when it comes to MAID, MacMillan says, “this is one of the few areas in medicine where patients and their family are overwhelmingly grateful for the care that I have provided.”

Even when a patient’s family initially disagree with MAID, MacMillan says that following the treatment they have “often changed their appreciation and acceptance of MAID potentially for themselves in the future.” In Lodge’s experience, patients have brought up concerns about getting a negative response when discussing MAID with family members and the doula says that “occasionally family dynamics will cause some challenges.”

Helping patients’ families so that the patient “can die in peace and know that their family is also being supported,” is part of the care Lodge provides. Generally, the response to MAID from patients and their families is positive. When family conflict arises due to individual beliefs, MacMillan says “100 per cent of the time, the loved ones who showed complete disagreement with the provision of MAID expressed their gratitude after.”

Due to patient confidentiality, neither of our local sources could provide details about the patients they have supported with MAID. However, according to Canada’s 2022 annual report on MAID, a majority of MAID patients had cancer (63 per cent) followed by cardiovascular (18.8 per cent), and the average age was 77 years. Only 1.3 per cent of MAID cases were people aged 18-45 and 3.2 per cent were age 46-55.

While MAID is an intensely personal decision, MacMillan knows the path he would choose.

“For myself, I believe that I can tolerate a fair amount…however, I would not want my family lingering at my bedside witnessing my suffering, worrying at night whether they’re going to see me the next morning and watching me decline to a fraction of the person that I was in life. I want to be able to give my family a proper goodbye and leave them with the memory of the person that I was in life, rather than leave them with a horrible, painful memory of a man who suffered deterioration and disappeared before their eyes.”

5 Comments

  1. Laurie says:

    Are these guidelines followed. Hearing of some cases that have not.

  2. Joan Stephens says:

    Thanks for the MAID. MY HUSBAND and I of 45 years each agree and have an advance directive. Still not legal in Ontario but legal in Quebec. My husband,80, has dimentia. It is my understanding that advanced directives are being debated in the Ontario legislature. Hopefully they will be legal by Feb 2025. Dimentia robs you of who you are. It is a most insidious disease.

  3. Mark says:

    A great alternative…given the state of Canadas “health care system”… kudos

  4. C. Wilson says:

    An excellent alternative for those of us who want an easier end. Thank you to the providers who are willing to take on this task.

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