Questions and Answers from the October 19, 2016 Vancouver All-Staff Forum

The following Q & A are from the October Vancouver All-Staff Forum on Medical Assistance in Dying. Questions were posed by forum participants, and have been answered by our featured speaker, Darren Kopetsky, Regional Director, Client Relations & Risk Management, Medical Affairs. For more information about Medical Assistance in Dying, visit VCH Connect. For Darren’s ASF presentation and the staff information package from the forum, click here. Specific questions can be directed to medicalassistanceindying@vch.ca.

Q:   Does provision of medical assistance in dying undermine a palliative philosophy that death is natural and inevitable, and that our role is to ease suffering?

A:    Palliative care and medical assistance in dying are different approaches of health care available to us in this region, as well as across Canada. In line with federal law, VCH offers both approaches as treatment/care options to patients who qualify for palliative care and/or medical assistance in dying. Patients who seek medical assistance in dying are eligible and should be offered all services, including palliative care so as to ease their suffering.

Q:   Method of medication – how is this decided by physician?

A:    The medication regimen in use in BC has been developed by a panel of experts of physicians and pharmacists, based on the experience in Quebec and Europe. The patient determines his or her choice of route of administration – oral self-administration or intravenous.

Q:   Does legislation recognize Advance Directives?

A:    The current law requires that a patient requesting medical assistance in dying be capable to make the decision at the time of each assessment, and at the final moment before administration. The law does not recognize a role for advance care planning or substitute decision makers in this particular care decision. The Federal Government has committed to review of the law in five years, at which time this and other aspects, which were the focus of much debate, will once again be considered.

Q:   Does a patient have to meet ALL the listed criteria?

A:    Yes.

Q:   How many assessors are there with VCH?

A:    All physicians and nurse practitioners may act as an assessor, whether with VCH or from the community.

Q:   Can staff refuse to assist?

A:    Yes, staff can decline to assist with the direct involvement such as participating in assessments, preparation, handling, or administration of the medications, or initiation of intravenous access for this purpose. However, other care must continue to be provided to the patient, including connection of the patient with information resources to help them to make a decision, and care for the patient and family following the medical assistance in dying procedure.

Q:   Can staff refuse, therefore, to assist with other issues that present a personal ethical dilemma?

A:    Staff should always discuss ethical dilemmas with their direct supervisor, preferably, prior to a care circumstance to provide adequate time for discussion and if warranted, reassignment of tasks during a shift.

Q:   Is a doctor always present, or are nurses ever left alone to do medical assistance in dying?

A:    Only a physician or nurse practitioner can perform the medical assistance in dying procedure, and will be present throughout that time. A nurse may be present to assist with IV access and / or support of the family, but does not handle or administer the medication.

Q:   How do staff deal with being “targeted” with comments of “killers” (similar to abortion clinics)?

A:    VCH staff maintain confidentiality and do not discuss procedures being provided to patients, other than on a need-to-know basis with other colleagues in the circle of care. The identity of providers who participate is sensitive information, and is restricted to those who need to know.  Staff experiencing any threat or harassment generally are encouraged to advise their supervisor, and if urgent, security or the police.

Q:   What safeguards are in place to avoid a patients being influenced by others to pursue medical assistance in dying?

A:    VCH joins the professional regulatory bodies in expecting that providers perform their role of providing information objectively so that patients can make choices among the options available to them. Staff who are concerned that colleagues are exerting influence – or impediment – in patient’s decision making concerning medical assistance in dying are invited to contact the Care Coordination Service, Medical Assistance in Dying, medicalassistanceindying@vch.ca / 1-844-550-5556.

Safeguards within the law include the following:

• a request for medical assistance in dying must be witnessed by two independent witnesses;
• all patients making requests are assessed by two separate physicians and/or nurse practitioners, whose responsibility includes assessment for eligibility, capability, and the absence of coercion or other influence, including at the moment immediately prior to administration of the medication; and
• there is a period of reflection of 10 days, which may be modified only with agreement of both assessors and the patient.

Q:   How are conscientious objectors to be supported by leaders?  

A:    VCH recognizes that some staff will not participate directly in the assessment or provision of medical assistance in dying, and expects that those staff will advise their supervisors of this decision, and that supervisors make arrangements to support the patient’s wish without that staff member’s direct involvement. More generally, VCH has engaged the Employee and Family Assistance Program to work with the managers to provide debriefing support for all staff in units and programs whose patients are seeking medical assistance in dying.

Q:   How is a conscientious objector not complicit if they provide a referral to other staff members?

A:    VCH uses the term ‘make an effective connection’ rather than ‘referral’, recognizing that ‘referral’ may imply an endorsement by the staff member. Making an effective connection does not suggest an endorsement, but does reflect (for all staff) the obligation as indicated by CRNBC’s Scope of Practice Standards for Registered Nurses that they “ensure that a client has access to the information that the client requires to understand all of their options and to make informed decisions about medical assistance in dying or other end-of-life options such as palliative care.”

Q:   Can patients with chronic and severe depression be approved for medical assistance in dying?

A:    While patients with mental health issues alone would not be eligible for medical assistance in dying, patients with chronic or severe depression or other mental health conditions may be eligible for medical assistance in dying if they meet all the other requirements.

Q:   Will guidelines specific to mental health teams be developed?

A:    There are no plans at this time. Staff looking for specific guidance are encouraged to review the resources at the policy implementation website, and pose any unanswered questions to their supervisor or medicalassistanceindying@vch.ca .

Q:   What is the quickest turnaround time from request to death (i.e. for someone with an urgent situation)?

A:    The period of reflection set out in law is 10 days; however, this time can be shortened if death is imminent or there is risk of the patient becoming incapable of making the decision during the period of reflection.  In order to shorten this period, both assessors and the patient must agree.