EL0M14 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Substitute Decision-Makers

• SDMs must adhere to the following principles when giving informed consent:

act in accordance with any wishes that were expressed when capable

if wishes unknown, act in the patient'

s best interest,taking the following into account:

1. values and beliefs held by the patient while capable

2. whether well

-being is likely to improve with vs. without treatment

3. whether the expected benefit(s) outweighs the risk of harm

4. whether a less intrusive treatment would be as beneficial asthe one proposed

• the final decision of the SDM may and should be challenged by the physician if the physician believes

the SDM is not abiding by the above principles

Instructional Advance Care Planning

•allow patients to exert control over their care once they are no longer capable

•the patient communicates their decisions about future healthcare,including who they would allow to

make treatment decisions on their behalf and what types of interventions they would/would not want

•to be used once the patient is incapable with respect to treatment decisions

•in Ontario, a person can appoint a Power of Attorney for Personal Care to carry out their advance

directives

the legal threshold to appoint a Power of Attorney for Personal Care is intentionally set lower than

the legal threshold for capacity to consent to many complex medical treatments,

’

this allows a

patient that lacks treatment capacity to appoint a person of their choosing to make the decision

for them

•patientsshould be encouraged to review these documents with their family and physicians and to

reevaluate them often to ensure they reflect their current wishes

Most provinces have legislated

hierarchiesfor SDMs:the hierarchy in

Ontario is:

• Legally appointed guardian

• Appointed attorney for personal

care, if a power of attorney confers

authority for treatment consent (see

Powers ot Attorney)

• Representative appointed by the

Consent and Capacity Board

• Spouse or common law partner

• Child (age16 or older) or parent

(unlessthe parent has only a right

of access)

• Parent with only a right of access

• Sibling

• Other relative(s)

• Public guardian and trustee

Other Types of Capacity Not Covered

by the HCCA

. Testamentary (ability to male a will)

• Fitness (ability to stand trial)

• Financial (ability to manage property

- Form 21 of the Mental Health Act)

• Personal (ability to care for oneself

on a daily basis)

. Substitute consentfor a procedure

whose primary purpose is research,

sterilization for non-therapeutic

purposes, or removal of organs or

tissue for transplantation (docs not

apply to those already declared

dead)

POWERS OF ATTORNEY

•all Guardians and Attorneys have fiduciary duties for the dependent person

Definitions

•Power of Attorney for Personal Care

a legal document in which one person gives another the authority to make personal care decisions

(healthcare, nutrition,shelter, clothing, hygiene, and safety) on their behalf if they become

mentally incapable

•Guardian of the Person

• someone who is appointed by the court to make decisions on behalf of an incapable person in

some or all areas of personal care,in the absence of a POA for personal care

•Continuing Power of Attorney for Property

legal document in which a person gives another the legal authority to make decisions about their

finances if they become unable to make those decisions

•Guardian of Property

someone who is appointed by the Public Guardian and Trustee or the courts to look after an

incapable person'

s property or finances

•Public Guardian and Trustee

acts as a SDM of last resort on behalf of mentally incapable people who do not have another

individual to act on their behalf

• Paediatric Aspects of Capacity Covered

no age of consent in all provinces and territories except Quebec; consent depends on patient’s

decision-making capacity

• Quebec has a specific age of consent, but common law and case law deem underage legal minors

capable, allowing these individuals to make their own choices

infants and children are assumed to lack mature decision-making capacity for consent but they

should still be involved in decision-making processes when appropriate (i.e. be provided with

information appropriate to their comprehension level)

adolescents are usually treated as adults

preferably, assentshould still be obtained from patient, even if not capable of giving consent

in the event that the physician believes the SDM is not acting in the child’s best interests, an

appeal must be made to the local child welfare authorities

under normal circumstances, parents have right of access to the child’

s medical record

There is no age of consent in Ontario

Capacity is assessed on an individual

basis

Negligence

n

L J

Ethical Basis

•the physician-patient relationship is primarily based on trust, which is recognized in the concept of

fiduciary duty, the responsibility to act in the patient’

s best interest

• negligence or malpractice is a form of failure on the part of the physician in fulfilling their fiduciary

duty in providing appropriate care and leading to harm of the patient (and/or abuse of patient’s trust)

Legal Basis

• physicians are legally liable to their patients for causing harm (tort) through a failure to meet the

standard of care applicable under the circumstances

+

EL0M15 Ethical,Legal, and Organizational Medicine Toronto Notes 2023

• standard/duty of care is defined as one that would reasonably be expected under similar

circumstances of an ordinary, prudent physician of the same training, experience,specialization, and

standing

• liability arises from physicians'

common law duty of care to their patients in the physician /patient

relationship (or in Quebec,from the Civil Code provisions regarding general civil liability)

• action(s) in negligence (or civil liability) against a physician must be launched by a patient within a

specific prescribed period required by the respective province in which the actions occurred

Truth-Telling

Ethical Basis

•helps to promote and maintain a trusting physician-patient relationship

• patients have a right to be told important information that physicians have regarding their care

• enables patients to make informed and autonomous decisions about healthcare and their lives

Legal Basis

• required for valid patient consent (sec Consent and Capacity, ELUMII )

• goal is to disclose information that a reasonable person in the patient'

s position would need in order to

make an informed decision ( “standard of disclosure")

• withholding information can be a breach of fiduciary duty and duty of care

• obtaining consent based on misleading information and/or insufficient information can be seen as

negligent and/or coercive

Evidence about Truth-Telling

• it is a patient’

s right to have the option of knowing about any clinical condition(s)/diagnoses that they

may have

• most patients want to be provided with information regarding their health

• although some patients may want to protect family membersfrom bad news, they themselves would

want to be informed in the same situation

• truth-telling improves trust, adherence, and health outcomes

• informed patients are more satisfied with their care and most often receive news about their health

better than expected

• negative consequences of truth-telling can include decreased emotional well-being, anxiety,worry,

social stigmatization, and loss of insurability

CPSO Policy on Truth-telling

Physicians should provide patients

with whatever information that will,

from the patient's perspective, have a

bearing on medical decision-making and

communicate that information in a way

that is comprehensible to the patient

Medical Error

• medical error may be defined as‘preventable adverse events (AEs)'

caused by the patient'

s medical

care and not the patient’

s underlying illness;some errors may be identified before they harm the

patient,so not all errors are truly ‘adverse’

• many jurisdictions and professional associations expect and require physicians to disclose medical

error; that is, any event that harms or threatens to harm patients must be disclosed to the patient or

the patient'

s decision-maker(s) and reported to the appropriate health authorities

• physicians must disclose to patients the occurrence of AEs or errors caused by medical management,

but should not suggest that they resulted from negligence because:

negligence is a legal determination

error is not equal to negligence

• disclosure allows the injured patient to seek appropriate corrective treatment promptly if possible

• physiciansshould avoid simple attributions as to the cause and sole responsibility of others or oneself

• physicians should offer apologies or empathic expressions of regret (e.g. “ I wish things had turned

out differently") as these may help to maintain and/or rebuild trust and are not admissions of guilt or

liability

• Apology Acts across Canada protect apologies, both as expressions of regret and admissions of

responsibility,from being used as evidence of liability and negligence

Errors of care are compatible with

non-negligent care if they are ones

that a reasonably cautious and skilled

physician could make (i.e. mistakes can

be made due to‘honest error')

Adverse Event

An unintended injury or complication

from health care management resulting

in disability, death, or prolonged hospital

nay

Breaking Bad News

•

‘bad news’may be any information that reveals conditions or illnesses threatening the patient’s sense

of well-being;different patients may classify‘bad news’in different ways

• disclosing medical information in a poor or insensitive manner may be as harmful as non-disclosure

caution patients in advance of serious tests and about the possibility of bad findings

give time for patient to reflect upon the situation prior to disclosing such news

give warnings of impending bad news by reviewing prior discussions

provide time for the patient to ask questions

adequate supports and strategiesshould always be provided following the disclosure of difficult

news

• SPIKES protocol was developed to facilitate “breaking bad news” in a conscientious and effective

manner

Setting, Perceptions, Invitation, Knowledge. Empathy, Strategy (see Palliative Medicine, PM6)

other toolssuch as the Serious Illness Conversation Guide or Vital Talk can also assist with

conversations with patients with serious illness

Examples of Warning of Impending

Bad News

Remember to clarify (invite) the level of

knowledge desired by the patient

“I have something difficult to tell you..."

"Unfortunately, the results are not what

we were hoping for..."

"This may come as a shock to you, but

the testsindicate..."

“There is no easy way for me to tell

this,so I will tell you straight away t

you have a serious problem..."

r n

you

hat +

F.L0M16 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

Arguments Against Truth-Telling

•may go against certain cultural norms and expectations

•may lead to patient harm, but only in extreme, rare situations

•medical uncertainty may result in the disclosure of uncertain or inaccurate information

Ethical Issues in Health Care

Managing Controversial and Ethical Issues in Practice

• discuss the issue(s) in a manner that is as objective and non-judgmental as possible

• ensure patients have full access to relevant and necessary information to make informed decisions

about their care

• identify if any options are outside of the physician’s moral boundaries (e.g.something to which the

physician has a conscientious objection) and refer to another physician if appropriate

• consult with a bioethicist and/or the appropriate ethics committees or boards

• protect freedom of moral choice forstudents or trainees

The Tri-Coundl Policy Statement

1. Genetic treatment aimed at altering

germ cells is prohibited in Canada

and elsewhere

2. Embryo research is permitted up to

14 d post-fertilization

3. Embryos created for reproductive

purposes that are no longer required

may be used

4. Gamete providers must give free and

informed consent for research use

5. No commercial transactions in the

creation and use of the embryos are

permitted

6. Creation of embryos solely for

research purposes is prohibited

7. Human cloning Is strictly prohibited

8. Risksof coercion must be minimized

(i.e.thefertility treatment team may

not be pressured to generate more

embryos than necessary)

9. One may only discuss the option

of using fetal tissue for research

after the patient makes a free

and informed choice to have a

therapeutic abortion

10. Physicians responsible for fertility

treatment may not be part of a stem

cell research team

Reproductive Technologies

•people of all gender identities may access reproductive technologies

• the words “maternal, mother, and woman” may refer to gender diverse individuals

Overview of Maternal-Fetal Considerations

• medico-legally, maternal body and fetal body are considered one. In general, maternal and fetal

interests align; however, in general/unless otherwise indicated via appropriate consent processes,

maternal health takes precedence

Ethical Issues and Arguments

• principle of reproductive autonomy: pregnant individuals have the right to reproductive choice (e.g. to

make decisions that align with their personal values, interests, and beliefs)

• coercion of an individual to accept medical advice is an unacceptable infringement of their personal

autonomy. It isimportant to empower individuals to make informed decisions about their medical

care in relation to pregnancy. This involves providing the individual with information about any

relevant benefits and risks in relation to recommendations, giving them time to ask questions and

reflect upon the recommendation(s), etc. A fine, but important,line exists between making a strong

recommendation and coercing an individual into consenting to a medical recommendation, the latter

of which must be avoided. A recommendation is, precisely, a recommendation (not forced)

• Canada’s colonial history includes a legacy of infringement of reproductive rights. It is important to be

mindful of one’

s own inherent power and privilege when engaging in conversations

• biases; It is important to be cognizant of one’

s potential biases in relation to reproductive decisionmaking. Ensuring that one'

s personal values and preferences do not unduly influence a patient’

s

decision-making process is of the utmost importance in order to enable autonomous decision-making

Legal Issues and Arguments

• the law protects a gestating individual'

s right to life, liberty, and security of person. Key aspects of the

gestating individual'

srights include;

• an individual with capacity (recognizing that capacity is decision- and time-specific) has the right to

consent or refuse to consent to any medical recommendations irrespective of whether or not they are

gestating. It is up to the treatment-proposing clinician to ensure that all relevant information related

to a medical recommendation (e.g.risks, benefits) is provided to help ensure informed decisionmaking

• the fetus docs not have legal rights until it is born alive and with complete delivery

• a pregnant person with comorbid substance use disorder cannot be detained and treated to protect the

fetus (Winnipeg Child and Family Services(Northwest Area) v. G.(O.F.), [1997] 3 S.C.R. 925)

• a fetus is not a “human being” within the meaning of the Criminal Code of Canada, thus medical

negligence during delivery resulting in the death of a fetus that has not been born alive does not

constitute criminal negligence causing death (manslaughter) and cannot attract criminal penalties( R

v Sullivan)

• Assisted Human Reproduction Act (20(H) principles:

The Parliament of Canada recognizes and declares that

(a) the health and well-being of children born through the application of assisted human

reproductive technologies must be given priority in all decisions respecting their use;

(b) the benefits of assisted human reproductive technologies and related research for

individuals,for families and forsociety in general can be most effectively secured by taking

appropriate measuresfor the protection and promotion of human health,safety, dignity and

rights in the use of these technologies and in related research;

(c) while all persons are affected by these technologies, women more than men are directly and

significantly affected by their application and the health and well-being of women must be

protected in the application of these technologies;

+

AL GRAWANY

EL0.M17 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

(d) the principle of free and informed consent must be promoted and applied as a fundamental

condition of the use of human reproductive technologies;

(e) persons who seek to undergo assisted reproduction procedures must not be discriminated

against, including on the basis of their sexual orientation or maritalstatus;

(f) trade in the reproductive capabilities of women and men and the exploitation of children,

women and men for commercial ends raise health and ethical concerns that justify their

prohibition;and

(g) human individuality and diversity, and the integrity of the human genome, must be

preserved and protected.

Assisted Reproductive Therapies

• includes noil

-coital insemination, hormonal ovarian stimulation, and IVI-

'

• some commonly referenced, ethically complex topics related to assisted reproductive therapies(ART)

include, but are not limited to;

» donor anonymity vs.child-centred reproduction (i.e. knowledge about genetic medical history)

preimplantation genetic testing for diagnosis before pregnancy

use of new techniques without patients appreciating their experimental nature

moralstatus of embryo

access to ART

private vs. public funding of ART

social justice factors influencing one'

s access to and/or experiences with ART (e.g. same-sex

couples having an opportunity to access welcoming, morally safe 2SLGBTQ1A+ spaces to receive

care)

the ‘

commercialization’of reproduction (e.g. surrogates)

Fetal Tissue

• pluripotent stem cells can currently be derived from human embryonic and fetal tissue

• use ofstem cells in research is reviewed by the Stem Cell Oversight Committee as part of the CIHR

• potential uses of stem cells in research:

studying human development and factorsthat direct cell specialization

evaluating drugsfor efficacy and safety in human models

cell therapy: using stem cells grown in vitro to repair or replace degenerated/destroyed/malignant

tissues (e.g. Parkinson'

s disease)

genetic treatment aimed at altering somatic cells (e.g. myocardial or immunological cells) is

acceptable and ongoing

Induced Abortion

• CMA definition of induced abortion:the active termination of a pregnane)’before fetal viability (fetus

>500 g or >20 wk GA)

• full CMA policy on induced abortion can be accessed here:https://www.cmaj.ca/content/ l 39/12/1176a

• after a CMA) publication in 2006,several letters to the editor were published, questioning the CMA'

s

position on induced abortion. In response, the CMA published clarification of their stance.This

clarification can be accessed here:Clarification of the CMA’

s position concerning induced abortion|

CMAJ (https://www.cmaj.ca/content/176/9/1310.l#ref-2)

Ethical and Legal Concerns and Arguments

• in Canada, there is no criminal prohibition regarding abortion

• termination of pregnancy is a medical and personal decision to be made in consultation with a

healthcare provider, alongside anyone else the patient wishes

• there exist various reasons as to why a person may inquire about and choose to pursue termination of

pregnancy

• termination of pregnancy is a value-laden and moralized topic. Healthcare providers, even those

who conscientiously object to termination of pregnancy,ought to treat all patients requesting such

termination with dignity, respect, and in a person-centred manner. It is of particular importance to be

cognizant of one’s own biases when caring for patients who want to receive a medical treatment that

does not accord with one'

s personal belief system and preferences

• if a medical practitioner does not provide termination of pregnancy, an effective referral to a willing

and available provider must be made without delay. From an ethics perspective,it isimportant to

demonstrate continued trustworthiness and support, recognizing that trusting one’

s providers can

influence health outcomes

• 2nd and 3rd trimester abortions are legal in Canada, but are usually, though not exclusively, pursued

when there are risks to the person'

s health, if the fetus died in utcro, and/or if the fetus has a known

major irreversible condition which may subject them to poor health outcomes upon birth (e.g.

anencephaly). In any of these cases, however, it is the choice of the pregnant individual

or not they will maintain or terminate pregnancy

ri

as to whether

Prenatal/Antenatal Genetic Testing

• uses:

1. to confirm a clinical diagnosis

2.to detect genetic predisposition to a disease

3.genetic testing/learning of predispositions may allow for preventative steps to be taken and help the

person prepare for the future

+

EL0M18 Ethical,Legal, and Organizational Medicine Toronto Notes 2023

4.gives parents the option to terminate a pregnancy or begin early treatment if/as applicable

ethical dilemmas may arise because of the sensitive nature of genetic information;important

ethical complexities and considerations related to genetic testing may include:

the individual and familial implications (e.g. how will learning about information confirmed

via genetic testing influence one'

sfamily dynamic?)

its pertinence to future disease

its ability to identify disorders for which there are no effective treatments or preventive

steps (e.g.should a person know if they/their fetus is genetically predisposed to an incurable

disease? Would the potential harms of knowing this information potentially outweigh the

benefits?)

its ability to identify the sex of the fetus, which may or may not be desired and/or relevant

information to ones decision-making

« obtaining truly informed consent is difficult due to the complexity of genetic information and

the inability to know precisely what will/will not occur as a result ofsuch testing (e.g. people

may receive unexpected and unwanted genetic information after consenting to the testing)

related to the above,consent to genetic testing and consent to disclosure of all genetic

information that results from the test may be distinct

some patients may want to be informed of genetic test results in particular ways (e.g. with a

support person present). In the case of delivering complex information, genetic counselling

maybe recommended

duty to maintain confidentiality vs.duty to warn family members (e.g. if a patient'

s

sister islikely predisposed to the same genetic condition as your patient, what are your

responsibilitiesto the sister, if any?)

» risk of psychological harm

risk of experiencing unjust social discrimination if such genetic information is disclosed to

certain parties

Legal Aspects

• as of 2017, the Genetic Non-Discrimination Act exists

• genetic testing requires informed consent

• physicians are obligated to inform patients that prenatal testing exists and is available

• in some specific circumstances, a physician may be able to breach confidentiality in order to warn

family members about a condition if harm can possibly be prevented via treatment or prevention.

In general, the patient’s consent is required, unless the harm to be avoided issufficiently serious to

rise to the level of imminent risk ofserious bodily harm or death (i.e. not a chronic condition, but an

acute life-threatening condition). It is recommended to consult with legal counsel and bioethics if

complexities arise in regard to breach of confidentiality/duty to warn

End-of-Life Care

Overview of Palliative and End-of-Life Care

•focus of care is comfort and respect for person nearing death and maximizing quality of life for

patient,family,and loved ones

palliative care is an approach that improves the quality of life of patientsfacing life-threatening

illness, through the prevention and relief of suffering, including treating pain, physical,

psychosocial, and spiritual concerns

•appropriate for any patient at any stage of a serious orlife-limiting illness

•may occur in a hospital, hospice, in the community, or at home

•often involves an interdisciplinary team of caregivers

•addresses the medical, psychosocial, and spiritual dimensions of care

•palliative sedation:the use ofsedative medicationsfor patients that are terminally ill to relieve

suffering and manage symptoms

•withdrawing or withholding life sustaining interventions (e.g. artificial ventilation or nutrition) that

are keeping the patient alive but no longer wanted or indicated

Palliative Care - Not the Same as

Medical Assistance in Dying

Palliative care is an approach designed

to improve symptoms and quality of

life for the duration of a person'slife,

but unlike Medical Assistance in Dying,

it docs not aim directly at or intend to

end the person'

slife. Many pallt.

care physicians are incorporatin

Illative

ig MAID

intotheir practice,though some may

conscientiously object

Medical Assistance in Dying

• medical assistance in dying: the administering or prescribing for self-administration, by a medical

practitioner or nurse practitioner, of a substance, at the request of a person, that causes their death

Common Ethical Arguments/Opinions

• criminally prohibiting medical assistance in dying may influence

lives and/or to endure intolerable suffering until their natural death occurs

• patient has the right to make autonomous choices about the time of their own death

• belief that there is no ethical difference between the acts of euthanasia/assisted suicide and forgoing

life-sustaining treatments

• belief that these acts benefit terminally ill patients by relieving suffering

• belief that patient autonomy has limits and that one cannot and/orshould not be allowed to make an

autonomous request to end one’

slife

• death should be the consequence of the morally justified withdrawal of life-sustaining treatments

only in cases where there is a fatal underlying condition, and it is the condition (not the withdrawal of

treatment) that causes death

some individuals to end their own

+

EL0M19 Ethical, Legal, and Organizational Medicine Toronto Notes 2023

•an argument presented in the Carter case (see below) suggested permitting MAID will detractsupport

for palliative care,since with proper palliative care, the number of requestsfor MAID would decrease.

This argument was rejected in Carter v. Canada,as it was deemed unacceptable to make people suffer

intolerably to potentially improve and/or increase support for palliative care

Legal Aspect

•in theCarter v.Canada decision of February 2015, the criminal prohibition on assistance in suicide

was ruled unconstitutional to the extent that they prohibit physician-assisted death for a competent

adult person who (1) clearly consents to the termination oflife and (2) has a grievous and irremediable

medical condition that causes enduring suffering that is intolerable to the individual in the

circumstances of his or her condition

•Bill C- 14 (|une 17, 2016) legalized MAID by amending the Criminal Code to create exemptions

permitting medical practitioners to provide MAID,specified the eligibility criteria,safeguards, and

required documentation and authorization from the Minister of Health, as well as new offences for

failure to comply with the new regulations. As the Bill C-14 criteria are narrower than the Carter

decision, there are ongoing constitutional challenges to the MAID framework asit currently stands

Bill C-14 Criteria for MAID

•patient is eligible for publicly-funded health services in Canada

•at least I8 yr, and has capacity for clear and freely given consent

•grievous and irremediable medical condition: in an advanced state of irreversible decline in capability

•suffering intolerable to the patient, not relieved under conditions they consider acceptable

•recent update eliminated criteria of “reasonable foreseeability of natural death”

•MAID process

1.eligibility criteria satisfied

2. patient signs and dates a written request for MAID

3.two independent witnesses sign the written request. Witnesses must be 18 yla, understand the

nature of MAID, and must not a) benefit (financially or otherwise) from the death, b) be an owner

or operator of the healthcare facility where the patient is receiving care, c) be directly involved in

the provision of health or personal care of the patient

4. healthcare provider must inform the patient that they can withdraw their consent at any time

5.two independent assessors(physician or nurse practitioner) must provide written confirmation

that eligibility criteria are met

6.10 clear days must elapse between the request and the day on which MAID is provided, unless

both healthcare providers agree that a shorter period is appropriate due to the patient’s imminent

death or loss of capacity

7. as per the new MAID legislation (updated in 2021),a patient may request MAID even if death

is not reasonably foreseeable, l

'

or a patient whose death is not reasonably foreseeable, their

eligibility assessment must be a minimum of 90 days unlessthe assessments are completed

sooner and the patient is at immediate risk of losing the capacity to consent.

8. throughout the 10 or 90 day period and immediately before providing MAID,the healthcare

provider must give the individual an opportunity to withdraw the request and ensure that the

patient gives express consent to receive MAID

• contravention of this process is an offence punishable by up to 5 yr in prison

9. as of changes to the legislation in 2021, a patient may waive the requirement for giving final

consent just before MAID is administered only if:(1) the patient'

s death is reasonably foreseeable

and (2) while the patient has decision-making capacity the patient is:

(a) assessed and approved for MAID

(b) advised that they are at risk of losing capacity to provide final consent and

(c) the patient makes a written arrangement with their health care provider where they

consent in advance to receive MAID on a chosen date if they (i.c. the patient) no longer

has capacity to consent on that date

Acceptable Use of Palliative and End-of-Life Care

•the use of palliative sedation with opioidsin end-of-life care,knowing that death may occur as an

unintended consequence (principle of double effect) is distinguished from euthanasia and assisted

suicide where death isthe primary intent

•the appropriate withdrawal of life-support is distinguished from MAID asit is seen as allowing the

underlying disease to take its'

natural course,'but this distinction may be more theoretical than real

•consent for withdrawal of life-support must be sought from the capable patient,or in case of incapable

patient the SDMs, as per the Health Care Consent Act and Substitute Decisions Act,and as re-affirmed

by the ruling in Cuthbertson v.Kasouli in 2013, as palliative care would be instituted and consent for

that would require SDM consent

•refusals of care by the patient that may lead to death as well as requests for a hastened death, ought

to be carefully explored by the physician to rule out any‘reversible factors’(e.g. poor palliation,

depression, poverty, ill-education, isolation) that may be hindering authentic choice

•Government of Canada - Services and Information for End-of-Life Care:

• https://www.canada.ca/en/health-canada/topics/end-life-care.html

• options and decision making at end of life: palliative care, Do Not Resuscitate orders, refusal or

withdrawal of treatment, refusal of food and drink, palliative sedation, MAID

decisions at end of life:capacity for informed consent,SDM, advanced care planning (written

plan, will,or medical directive) often established through a family meeting

MAID:Ethically Appropriate Actions

• Respect capable decisions to forgo

available treatment options and/or

palliative care options

• Provide appropriate palliative

measures with patient consent

• Try to assess reasons for MAID

requests to see if there are

'reversible factors' that are directly

and unduly influencing one's desire

to receive MAID (e.g. depression,

pain, loneliness,anxiety) that can

be treated

Exploring the Experience of Supporting a Loved

One through a Medically Assisted Death in

Canada

Can fam Plryscian.201S:64|5|:e38?-e393

Purpose: To explore the experience of family and

dose friends of patentsseeking MAID In Canada.

Methods: Primary support givers ol clinic patients

seeking MAID were rdentihed during consultations

lor an assisted death evaluation.The idenblied

support giverswere then invited to participate in the

study, and those interested were asked to contact

interviewers.Semi-structured interviews were

conducted, transected.coded,and subjected to

content analysisto elucidate com mon themes.

Aesults: 18 support peoplefor patientsseek log MAID

were interviewed.Ail participantswere supportive

ol their loved one'swithesfor MAID and provided

emotional and practicalsupport in preparation lor

the procedure.Some participantsreported feeing

opposed,however,changed their minds afterseeing

the suffering their loved ones had toendure.The

time before the procedure involved saying goodbye

and ceremonial rituals.Those interviewed alter the

procedure found thedeath peaceful and reported that

it offeiedadranlaget compared with natural death in

their I oved one'sindividual circumstances.

Conclusion:Participants were supportive of their

loved one's wisheslor assistance in death to end

suffering and foatd the pmcessto be peaceful

overall.

n

L J

+