My first blog of the New Year  may be about death. But it is about having as good a death as possible- (in your own bed while asleep) and of your choosing…..A recent  blog was about  a fellow who wanted to ensure his dying wishes would be followed which involved tattooing ‘Do Not  Resuscitate’ on his chest.  DNR wishes, for me, apply when our health deteriorates or something unexpected occurs.

On the other end of the spectrum is planning for an exact death towards the end of the journey, with place and timing determined in advance, I am specifically referring to  Medical Assistance In Dying (MAID) which came into effect in June 2016.

Bill C-14   provides the ability for terminally ill and suffering patients to choose how to end their lives.

The following description and explanation is taken directly from the Dying With Dignity  website:

What types of MAID are permitted in Canada?

In Canada, two types of MAID are allowed:

1. A physician or nurse practitioner can directly administer a substance that causes the death of the person who has requested it, and
   2. A physician or nurse practitioner can give or prescribe to a patient a substance that they can self-administer to cause their own death.

Who is eligible for MAID in Canada under the new law?

Under Bill C-14, two independent health care professionals need to evaluate an individual in order to determine whether he/she qualifies for MAID. To qualify, an individual must be 18 years or older and meet the following four eligibility criteria:

1. Have a serious and incurable illness, disease, or disability;
   2. Be in an advanced state of irreversible decline in capability; 
   3. Endure physical and psychological suffering that is intolerable to them; and
   4. Their natural death has become reasonably foreseeable.

Patients must also be capable of providing informed consent at the time that MAID is provided.

How does the new law differ from the Supreme Court’s Carter decision?

Bill C-14 is much more restrictive than the Carter decision. The Carter decision made assisted dying available to any consenting, competent adult suffering intolerably from a grievous and irremediable medical condition. However, the new law includes two provisions that are much narrower in scope. To qualify for assisted dying under Bill C-14, an individual must be in an advanced state of irreversible decline and their natural death must be “reasonably foreseeable.” The vague language of the eligibility criteria — specifically this “reasonably foreseeable” clause — makes the new law ambiguous at its best and unconstitutional at its worst.

Despite assurances from the federal government that individuals do not have to be terminal in order to qualify, medical practitioners will ultimately have to interpret the eligibility criteria for themselves. There is a strong chance that many providers will interpret the “reasonably foreseeable” clause to mean that only those individuals whose deaths are imminent will qualify for MAID. In fact, some Canadian doctors have already been advised by lawyers to err on the side of caution and to only provide MAID to those who are terminally ill.

This means individuals who were granted the right to a peaceful death by the Supreme Court may now found themselves barred from access. For example, patients with excruciating conditions like ALS, Multiple Sclerosis, and Parkinson’s disease are at risk of being denied a dignified death because their deaths may not be imminent. Other individuals, like those who have endured a serious stroke or a series of strokes, may also be trapped in intolerable suffering with no natural end in sight. For many of these individuals, this intolerable suffering can persist for years, and to force them to continue languishing in agony is exactly the kind of fate the Supreme Court ruled against.

What procedural safeguards are required in Bill C-14?

If the individual meets all the eligibility requirements and has clearly consented to an assisted death without any external coercion, they must submit a written request in the presence of two independent witnesses. Once the patient’s doctor (or nurse practitioner) determines that the patient is eligible for MAID, a second doctor or nurse practitioner — independent of both the first doctor and the patient — is required to give a second opinion on the patient’s eligibility. If both agree that the patient is eligible, MAID can be granted.

There is a mandatory reflection period of at least 10 days that needs to occur between the day the patient signed the written request and the day MAID is provided. However, if death or loss of capacity to provide informed consent is imminent, the reflection period may be reduced.

Could a person with dementia qualify for MAID?

Under the new law, advance requests for dying are not permitted. This means Canadians with diagnoses of competence-eroding conditions like Alzheimer’s and Huntington’s disease will not be granted the right to consent while they are still of sound mind to an assisted death that would be carried out at a later time.

Without advance requests, these individuals will most certainly be found ineligible for MAID because they will likely lose competence before they reach the required “advanced state of irreversible decline” outlined in the eligibility criteria.

The government has initiated an independent review to study advance requests, but there is no guarantee that access to MAID through advance requests will ever be allowed under the law. That means individuals with conditions like dementia may never qualify for MAID.

According to an October 6, 2017 Toronto Star article from June to Dec, 2016, there were 803 MAIDs  in Canada. From Jan to June 2017 this increased to 1,179 MAIDs.  Cancer was the most frequent medical condition and the patient average age was 73. I found this relatively young age surprizing.

There is still much to figure out.  I have written extensively about Advanced Directives and continue to stress the importance of discussing, deciding and writing down one’s wishes.

If you are looking for more information about MAID:

https://www.health.gov.on.ca/en/pro/programs/maid/

https://www.ontario.ca/page/medical-assistance-dying-and-end-life-decisions