In one case, an Ontario man in his late 40s with debilitating ulcers was granted medical assistance in dying, despite a litany of mental disorders and previous suicide attempts.
In another, a woman in her 50s with a history of depression, anxiety and suicidality received MAID in part because she couldn’t find housing that would relieve her suffering from multiple chemical sensitivity syndrome, a rare condition in which pain, fatigue, rashes and other ailments arise from mild exposure to chemicals.
In a third, a man in his 40s with inflammatory bowel disease who was socially isolated and addicted to opioids and alcohol was told about MAID during a psychiatric assessment. His family wasn’t consulted beforehand, and the MAID provider drove him to the location where he received an assisted death.
Those are three of the cases highlighted in two new Ontario reports that reveal the challenges of determining MAID eligibility for people with serious illnesses and disabilities whose natural deaths aren’t imminent.
Those examples aren’t typical, but were summarized to illustrate complex cases where patients’ suffering was exacerbated by social vulnerability or complex medical conditions, according to a MAID death review committee established by the Office of the Chief Coroner of Ontario last January.
The committee’s first reports, which were sent to MAID providers across the province on Thursday, also revealed that rates of medical assistance in dying for non-terminal illness were higher in poorer neighbourhoods, although there were relatively few such cases overall.
Last year in Ontario, 116 of 4,644 MAID provisions, or 2.5 per cent, were identified as “track two,” a category reserved for patients whose deaths aren’t reasonably foreseeable. That’s down from 121 such cases in Ontario the year before.
“MAID has uncovered and put a light on these vulnerable people,” said Konia Trouton, a member of the review committee who is also president of the Canadian Association of MAiD Assessors and Providers, or CAMAP. “I think clinicians who are jumping into this work do have to engage more in very careful analysis of everything that might impact someone’s ability to cope.”
It’s not clear if any of the doctors or nurse practitioners involved in the cases described in the reports faced consequences. Dirk Huyer, the province’s chief coroner, declined to speak about individual cases.
However, he provided data to The Globe and Mail showing that, since 2018, the coroner’s office has made five MAID-related referrals to regulatory bodies that govern health professionals and have the power to discipline them. The coroner’s office has not referred any MAID cases to police, he added.
Ontario has a dedicated team of nurse coroners who review about 400 MAID cases a month after the fact, according to Dr. Huyer. The new 16-member expert committee’s job is to identify worrisome trends or shortcomings in how MAID is being carried out, and to recommend improvements to governments, regulators and front-line providers.
Medical assistance in dying became legal in Canada in 2016 after the country’s highest court struck down the Criminal Code prohibition on assisted suicide. A federal law adopted that year limited MAID to people whose natural deaths were “reasonably foreseeable,” a stipulation that meant most recipients had terminal cancer.
But in 2019, a Quebec judge found the reasonably foreseeable death clause to be an unconstitutional barrier that forced a pair of Quebec patients with incurable conditions to keep living in great pain. Rather than appeal the ruling, the federal Liberal government rewrote the law to create two pathways to MAID. Track one is for patients whose deaths are reasonably foreseeable, and track two is for those whose deaths are not.
Track two has guardrails to protect the vulnerable, including a 90-day assessment period.
”The government set up track two to balance the rights of access, while considering the protection of the vulnerable,” said Ramona Coelho, a committee member and London, Ont., family doctor who cares for patients with complex physical, mental and social conditions. “Vulnerable could mean many things, but it should also include people who our society and policies have failed and they’re suffering from that, right? That’s an important consideration. Are we allowing these people, because of lack of care, to die?”
The cases summarized in the new reports make plain the difficulty of assessing patients for MAID eligibility when they have severe mental-health challenges. Ottawa has twice postponed the implementation of legislation that would have expanded eligibility to people whose sole underlying illness was a mental disorder.
As the law stands, patients must have incurable physical illnesses to qualify. Having a concurrent mental illness doesn’t disqualify applicants, so long as two doctors or nurse practitioners conclude they have the capacity to consent.
Among the recommendations in the reports is a call for a provincially co-ordinated MAID care system that would help community doctors who provide MAID connect vulnerable requestors with social supports, housing and mental-health care during the 90-day assessment period.
”It’s tragic that people’s quality of life is so poor that they want to explore MAID,” Dr. Trouton said. “So what happens when they don’t have that underlying [physical] disease, but they’re clearly having poor quality of life? How do we help them? How do we get the supports in place?”
Hannah Jensen, a spokeswoman for Ontario Health Minister Sylvia Jones, said the Ministry of Health and Ontario Health would review the recommendations.