Medical assistance in dying (MAID) : the Québec Experience Banff Seminar, March 17-19 2017

Disclosure

Linda Vaillant, Executive Director (A.P.E.S.) I have nothing to disclose. I have no current or past relationships with commercial entities and I have received no speaker’s fee for this conference.

François Paradis, President (A.P.E.S.) I have nothing to disclose. I have no current or past relationships with commercial entities and I have received no speaker’s fee for this conference.

Learning objectives

1.  Give an overview of the political issues related to the implementation of MAID in Québec

2.  Present the process and the involvement of pharmacists in MAID

3.  Explain the protocols and the choice and use of drugs selected for MAID

Plan of the presentation

1.  Historical perspective of MAID in Québec

2.  Walking through the process of MAID : the story of Paul

3.  Pharmacological considerations

4.  One-year experience in Québec : looking back

5.  Consequences in Québec of the Carter v. Canada decision and of the C-14 Bill

1. Historical perspective of MAID in Québec

•  Consultation process and social consensus o  The « Dying with Dignity Commission » (created on December 4th 2009 ; report submitted on March 22nd

2012)

•  The law on end-of-life care was adopted in June 2014 and entered into force on December 10th 2015

•  A.P.E.S. involvement in the implementation of MAID o  Parliamentary committee presentation (September 2013) o  Practice guidelines and protocols (2 hospital pharmacists representing A.P.E.S. on the College of

physicians’ committee) o  Issues with community pharmacists and access to drugs

•  Information and training for health professionnals

Guides from the regulatory bodies

2. Walking through the process of MAID : the story of Paul

Case report

•  Paul is a 68 year-old patient who has been diagnosed with a metastastic lung cancer 10 months ago. He’s been hospitalized for three weeks and has now entered in the terminal phase of his illness. Pain is relatively well controlled with medications but he’s experiencing increased shortness of breath, causing him great distress.

•  Today, considering the whole situation, and even though his wife and chidren don’t agree with his decision, he asked his doctor for medical aid in dying.

•  Let’s now follow Paul in the process of MAID.

2. Walking through the process of MAID : the story of Paul

Criterias to obtain MAID (all of the following must apply) •  Be an insured person under the Health Insurance Act •  Be of lawfull age (18 yo in Qc) and capable of giving consent to care •  Be at the end of life •  Suffer from a serious and incurable illness •  Be in an advanced state of irreversible decline •  Experience constant and unbearable physical or psychological suffering which cannot be

relieved in a manner the patient deems tolerable

2. Walking through the process of MAID : the story of Paul

Decision-making process

•  Capacity to consent to care •  MAID requested by patient himself and written consent provided •  Physician has to provide the patient with adequate information about :

o His illness o The medical diagnosis o His life expectancy o The various possible treatments and intervention options, both curative and palliative

2. Walking through the process of MAID : the story of Paul

Decision-making process

•  Medical decision o Assessment of criterias o Medical judgment o Conscientious objection by the physician

•  Discussions with the interdisciplinary team, the patient and his family

•  Opinion of a second physician

2. Walking through the process of MAID : the story of Paul

Pharmacist’s role in MAID •  The physician and the pharmacist must discuss :

o Patient’s medical and drug history o Protocol selected o Scheduled time and day for the administration of MAID o Time required to prepare medications o Completion of the medication administration record o Procedures for returning unused products to the pharmacy

The prescription

2. Walking through the process of MAID : the story of Paul

Pharmacist’s role in MAID

•  Preparation and storage of medications

o Prepared in sterile conditions in ready-to-use syringes numbered in the order of administration

o Presented in a sealed kit o Second kit containing a duplicate set of the products and injection material must be

systematically prepared and sealed, in the event of damage or improper handling

2. Walking through the process of MAID : the story of Paul

2. Walking through the process of MAID : the story of Paul

2. Walking through the process of MAID : the story of Paul

Pharmacist’s role in MAID

•  Dispensing of medications

o Medications must be dispensed directly to the physician o Unused products and material must be returned to the pharmacist by the physician o Unused products and material must be destroyed by the pharmacist and the

physician o Medication administration register must be completed by the pharmacist and the

physician

•  Conscientious objection by the pharmacist is possible

2. Walking through the process of MAID : the story of Paul

3. Pharmacological considerations Administration of MAID •  Intravenous injection only

o Good venous access is an absolute prerequisite o Central line if peripheral venous access impossible o Assessment of venous potential within 24 hours prior to the administration o Venous line placement within 4 hours prior to the administration

The administration records

3. Pharmacological considerations

3. Pharmacological considerations

3. Pharmacological considerations MAID : a three-step process •  Step 1 : Anxiolysis

o Midazolam 2,5 to 10 mg IV over 2 minutes •  Step 2 : Artificial coma induction

o For local analgesia : lidocaine 2% (without E) 2 mL IV over 30 seconds OR magnesium sulfate 1000 mg IV over 5 minutes (if allergy to lidocaine)

o Propofol 1000 mg IV over 5 minutes OR phenobarbital 1000 mg IV over 5 minutes (if allergy to propofol)

o Coma must be confirmed before going to step 3

3. Pharmacological considerations MAID : a three-step process

•  Step 3 : Neuromuscular blocker injection

o NaCl 0,9% 10 mL IV (flushing the tubing) o Cisatracurium 30 mg by rapid direct IV injection o NaCl 0,9% 10 mL IV (flushing the tubing) o  If cisatracurium not available, rocuronium 200 mg can be used

•  STEPS 1, 2 AND 3 MUST BE COMPLETED

4. One-year experience in Québec : looking back

•  From December 10th 2015 to June 30th 2016 : Report from the End-of-life care Commission :

o  253 demands for MAID in total of which 166 were administered

o Of the 87 demands not administered :

Ø 36 did not fill the criteria Ø 24 withdrew their demand Ø 21 died before the administration of MAID Ø 5 were under evaluation at the date of the report Ø 1 postponed the demand for later

o  263 continuous palliative sedation also reported

4. One-year experience in Québec : looking back

•  From June 10th to December 10th 2016 : Report from the End-of-life care Commission :

o 468 demands for MAID in total of which 295 were administered

o  Therefore over a year : over 450 MAID were administered (461 but overlap between June 10th and June 30th)

5. Consequences in Québec of the Carter v. Canada decision and of the C-14 Bill

•  February 6th 2015 :

o Carter v. Canada invalidates the articles 14 and 241b of the criminal code prohibiting an individual to consent to death or to help someone to die

o That decision was suspended for one year by the Supreme Court to let the federal government modify the criminal code accordingly

•  December 1st 2015 :

o The Québec Superior Court was asked to suspend the application of the new law in Québec that was to come into force on December 10th

o The Judge Pinsonneault decided that the federal law took precedence over the provincial law and suspended its application

5. Consequences in Québec of the Carter v. Canada decision and of the C-14 Bill

•  December 9th 2015 :

o  The Appeal Court accepted the request to appeal from the Government of Québec o  That decision suspended the Pinsonneault’s judgment

•  December 10th 2015 :

o  The law on MAID came into force

•  December 22nd 2015 :

o  The Appeal Court invalidated the Pinsonneault’s judgment and declared that there was no precedence of the federal law over the provincial one

o  The law on MAID was then applied

5. Consequences in Québec of the Carter v. Canada decision and of the C-14 Bill

•  January 2016 :

o  At the request of the Federal Government, the Supreme Court accepted to prolong the suspension of the declaration of invalidity of the articles 14 and 241b of the criminal code for 4 months

o  The Québec Government had requested to be exempted from that extension which was accepted by the Supreme Court ; for a matter of equity, the Court also accepted that individual demands of exemptions from provinces be possible

•  June 17th 2016 :

o  Bill C-14 came into force o  The Québec law now needs to be changed because it is more restrictive than the federal

law, especially with respect to the notion of death reasonably foreseeable and self administration