A High Quality Care Pathway for Patients Requesting Medical Assistance in Dying (MAID)

With the introduction of Bill C‐14 on June 17, 2016, medical assistance in dying (MAID) became legal in Canada. This followed over a year of debate about this ethically contentious issue after the Supreme Court of Canada ruling in Carter v. Canada (February 2015), which stated that the absolute prohibition of MAID violated constitutionally protected rights.

Under this new legislation, patients meeting clearly defined eligibility criteria are permitted to access assistance in dying after following a clear process for being assessed and providing informed consent. At The Ottawa Hospital (TOH), a voluntary and interdisciplinary team of clinicians and administrators was brought together to navigate this very challenging issue, and provide compassionate care to patients under extremely difficult circumstances at the end‐of‐life.

Pre‐Legislative Approach

Prior to the legislation being passed, TOH created two interdisciplinary working group with patient representation. Other staff groups represented on these committees included Ethics, Nursing, Social Work, Spiritual Care, Physician Leadership, Patient Advocacy, and Senior Management. One of these groups worked on the development of corporate policy, while the other laid the groundwork for the operations required to deliver the service. The Chairs of these two groups regularly communicated and provided reports to the opposite committee on key issues, challenges, and decision points. These groups documented all meetings, and maintained regular communication with the organization’s Senior

Management Team, Patient and Family Advisory Council, and Board of Governors.

With respect to policy development, the following critical issues were identified and addressed:

• Defining the organization’s position on MAID, relative to the organization’s mission, vision, values and strategic directions;
• Protecting the right of health care providers to conscientiously object, while ensuring access to care;
• Clarifying and further defining eligibility criteria articulated in BillC‐14;
• Formalizing a core group of regulated health care professionals for standardized and high quality service delivery (the MAID Assessment Team);
• Defining expectations of TOH staff as they respond to this challenging issue;
• Defining oversight and accountability for this new practice through the creation of a MAID Internal Resource Group that meets regularly to provide retrospective review of cases where MAID is provided.

At the same time, the team working on operational issues identified and addressed the following questions:

• Defining the clinical pathway for patients to receive two assessments of eligibility by independent physicians, and ultimately receive MAID within a reasonable timeframe (identified as <28 days). This included further delineation of pathways for inpatients and outpatients, and consideration of impacts to groups such Health Records, Admitting, and Logistical Services;
• The infrastructure, capital and human resources required to provide MAID in a responsive, compassionate and supportive manner. This included identification and modification of appropriate physical space, and consideration of appropriate staffing levels;
• Designing a pharmaceutical protocol for MAID that would-be patient‐centered and evidence‐based;
• Ensuring that patients, families and staff receive appropriate psycho‐social support as they move through the MAID pathway;
• Championing the need for continuous staff support for those staff participating in the delivery of MAID.

The work of these two groups ultimately led to the approval of a corporate policy for MAID, with a commitment that the policy would be regularly revised as new legislative or clinical practice changes emerged. In addition to the policy, there was an equal effort to identify staff willing to participate in the MAID process. This resulted in a large “Town Hall” event in May 2016 to provide information to staff who might be willing to join the frontline MAID Assessment Team. These outreach activities resulted in the recruitment of physicians, nurses, social workers and spiritual care providers ready and willing to support patients through the MAID pathway. Simultaneously, the MAID Internal Resource Group began to meet and define a term of reference for case review and continuous quality improvement. To the credit of those working on this issue, these objectives were met prior to Bill C‐14 being passed into law on June 17, 2016. Thus, there was no identifiable impact on patients requesting access immediately following decriminalization. This was a very significant achievement, given the relatively small amount of time allotted to develop this service.

Post‐Legislative Practice

After implementation of Bill C‐14, TOH was in the position to ensure immediate access to MAID through a robust and patient centered process. This pathway includes:

• Centralized intake of formal written requests through the Department of Clinical and Organizational Ethics;
• Triage to independent physicians who conduct assessments of eligibility, with an effort to engage primary care and attending physicians in the process while being respectful of any conscientious objection;
• Social Work support for patients and families at the time that the patient receives second assessment of eligibility;
• Standardized communication between Intake, Health Records, Admitting, Pharmacy, and the Coroner’s office;
• In cases where the mandatory 10 day waiting period is shortened, additional documentation and justification is provided;
• Notification to TGLN based on legislative requirements;
• Provision of MAID, either:
  • For inpatients, in a private room on the inpatient unit;
  • For outpatients, in a designated private room during defined off‐hours to ensure privacy.
• Provision of MAID includes:
  • Two nurses;
  • At least one physician, and the physician must have assessed the patient’s eligibility;
  • One social worker;
  • Administrative support for ensuring appropriate coordination, documentation and communication.

Given the challenging nature of the issue in question, appropriate staff support was also identified as a priority. To fill this gap, a resiliency program was developed by a psychologist and a psychiatrist.

Through collaboration with Lieutenant Colonel Bailey (Department of National Defense), one of the creators of the Road to Mental Readiness, the resiliency training provided to the Canadian Armed Forces was adapted for the Physicians and Staff providing MAID. This program provides support and resources to the MAID team before, during and after the intervention, and involves data collection to monitor staff wellness and tailor future interventions to identified needs. To further support staff, the Department of Clinical and Organizational Ethics developed a draft “Reference Manual”, which includes 14 sections outlining each aspect of our program. TOH’s future plans will include an annual “Resiliency Bootcamp” for those participating in the MAID process ‐ which will be based on focus groups (February 2017) that will refine content – as well as the development of a Community of Practice.

There was also recognition that the pathway identified above was of primary benefit to patients wishing to receive MAID in an acute care environment.

While this pathway may be appropriate for a certain patient population, there was an understanding that it may not be the most patient‐centered model for patients wishing to die in alternative locations, such as private residences, Long Term Care (LTC), or retirement homes. For this reason, our team worked actively with the Champlain Community Care Access Centre (CCAC) to establish a process for provision of MAID in the community, which has also been successfully implemented.

While actively caring for patients moving through this pathway, our program has also provided expertise to many other health care organizations in the Champlain Local Health Integration Network (LHIN), including hospitals, complex continuing care, community care, and the LHIN itself. This work includes participation in a regional working group that is organizing a regional conference on MAID in March 2015, with many workshops being implemented by TOH physicians, nurses, social workers, psychology, and psychiatry. These outreach activities have and will continue to build the capacity of our regional partners in responding to this difficult issue. This is of “particular” importance given the geographical layout of our LHIN, where there is a real concern that patients may feel the need to travel long distances to receive MAID away from their home communities.

Oversight and Evaluation

As mentioned above, the MAID Internal Resource Group, which reports to the Medical Advisory Committee, meets regularly to audit cases where MAID has been provided and make recommendations for quality improvement. This group has reviewed each case to ensure that appropriate documentation existed, that wait times were in line with the target of <28 days, and that cases where MAID is provided less than 10 days after written request are aligned with legislative requirements.

With respect to wait times, patients have only waited longer than 28 days from receipt of request to provision of MAID in cases where a longer period was desired by the patient. Our audits have also determined that the majority have the option of receiving MAID within 2‐3 weeks of receiving a written request. This is exceptional in terms of access to a new clinical service with relatively few human resources. In several cases, we have also shortened the 10-day waiting period based on clinical need (i.e. impending loss of decision‐making capacity). These efforts have resulted in an optimized patient experience under challenging circumstances.