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Episode 9: Medical assistance in dying

November 12, 2020

In 2016, the federal government legalized medical assistance in dying. However, it remains a controversial and sensitive topic, with some care providers refusing to do it.

We talk to Dr. Beverly Adams, the senior associate dean of education at the Cumming School of Medicine, about how medical assistance in dying can offer choice and dignity to grievously sick patients and how medical schools are adapting to the practice.

Mike MacKinnon (MM): Welcome to We Can Answer That. I'm your host, Mike MacKinnon. Each week, I sit down with an expert from the UCalgary community to ask five questions related to their field of study and to shed light on the topics that matter most. In 2016, the federal government passed legislation that made it legal for healthcare providers to offer medical assistance in death. In Alberta, this program is called MAID, for medical assistance in dying. Assisted dying has always been a controversial and sensitive topic and making it legal doesn't change that. The laws are pretty strict about who's eligible for assisted dying. Also, a lot of doctors choose not to do it for moral, ethical, or religious reasons. Today we're joined by Dr. Beverly Adams, who is the senior associate dean of education at the Cumming School of Medicine, to talk about how medical schools have changed their curriculums to adapt to assisted dying. Bev, thanks for joining us.

 

Dr. Beverly Adams (BA): Thanks for having me.

 

MM: Let's talk about the bigger picture first. What's the benefit of legalizing assisted death?

 

BA: So I think when we talk about medical assistance in dying, it does tend to evoke negative connotations. And so I would just like to address that first off I see MAID, if we'll call it for short, as an opportunity for patients to have choice in their care and it's something we've actually been doing, we actually do it every day in medicine because we talk about goals of care and what those opportunities are. And so I see medical assistance in dying as another opportunity to discuss those options. I think patients should have choice in their care, and I think there should be partly their decision as long as they can provide consent and are competent to make those decisions. And that's why the regulations around it are so strict. It gives the patient an opportunity to decide their course. And just to reiterate that these are very grievous and irremediable medical conditions. And so for the patient to participate in their care in that way, it's very important for them and their family. And we always practice patient-centered care. So discussing goals of care is not new, but indeed this legislation is relatively new. And I think it's most important to have that conversation with patients and their families.

 

MM: So it still seems to be a controversial topic for some healthcare providers. Why do you think that is?

 

BA: So I think not all healthcare providers are comfortable with MAID and the federal practice may not be consistent with a provider's beliefs and values. And so the federal legislation does not force any person or practitioner to provide MAID, but it does allow patients to apply for that opportunity, to have that choice. And so I think that's why it can be difficult for some healthcare providers and that you don't have to provide the care yourself, but I think it does behoove you as a medical practitioner to make recommendations to the family as to where they can achieve MAID if required. So you don't have to do it personally, but I think you have to be aware of the opportunity to provide that for your patient.

 

MM: How has medically assisted death changing the way we train healthcare professionals?

 

BA: In the Cumming School of Medicine, there are a number of touch points and in any doctor's medical education training, there's a continuum of training. And so you start in the medical school where you would have a topic brought up in ethics and so MAID would be discussed in ethics in medical school and the concept of MAID. And along with discussing goals of care and patient care, it would be raised in medical school. Then once you're done medical school, but you're never really done, you move on to become a clerk on inpatient rotations. And so then again, there's always a hierarchy of structure. So as a medical student, there'd be a resident head of you and then the attending physician. And so you then move into that realm where you are actually in a patient care setting, where you have gained practical experience with some of these concepts. Then after you complete your medical school training, you go into a match and you do your residency training. So whether you want to be a family doctor, you want to be a specialist, you then go on to learn more in your rotations. And again, that's very much a practical setting while always having academic half days to look at the theory behind what you're doing, but you actually get firsthand experience. And again, under the supervision of a practicing physician. And so looking at some of our rotations where that might happen, it would be particularly prominent on palliative medicine and there, they would have a full academic half day session on MAID, a one-hour interactive presentation on information related to MAID. And then you'd have a three-hour case-based session with a simulated patient to practice responding to patients' requests about made. So again, it's nice to have that opportunity to have a simulated setting, as well as the actual experience on an inpatient basis. Family medicine is another place where there's a touch point for MAID. And so in their foundations year in their first year of training, there is an introduction to the topic in their first month of training about its legal premise and professional and personal responsibilities as a family doctor. And then in their second year of training, there's an academic half day, and they've got a three-hour session about how to manage this issue practically when it arises in your practice. And then they also do a palliative care rotation, which covers this topic with small group sessions. And then they also have weekly academic sessions with small groups where they would discuss these kinds of issues. So I guess, as you can see, there are many touch points in a physician's career where you would understand MAID and the concepts behind it. So from theory in the classroom to simulated training, as well as inpatient experience, as you mature and progress in your medical school training. We often speak about the continuing of education from undergraduate to postgraduate, which is residency training, and then you're onto continuing medical education. So that's what I mean by you're never done as a physician. And so continuing medical education is very important for those practitioners who maybe didn't get the same fulsome experience or opportunity or information about MAID. There are also continuing medical education opportunities to learn about MAID. I don't want to ever forget that end of the continuum from medical school right up to practicing physician, because it's an ongoing process.

 

MM: Now, once the patient's life has ended, how do healthcare professionals care for the people that are left behind?

 

BA: As a psychiatrist, I think it's really important to begin with the conversation ahead of time. And I think everyone involved in the MAID process would be particularly important to adhere to that. So I think when you have a conversation, you involve the patient, their family or their choice of family members present. And so I think that's the first part of a very fulsome discussion that needs to happen. And I think if you don't pay attention to some of the feelings afterwards, you can run into some difficulties. So it's just like, you can imagine making a decision and then when it's done it's, "Oh, should we have done that?" And I think sometimes families might face that. So I think it's really important at the beginning to stress what the goals are. And a lot of the reasons people choose to pursue MAID is loss of autonomy, loss of independence, loss of purpose, and enjoyment, physical and communication abilities, suffering, fear of future suffering. But the biggest thing is loss of autonomy. And so I think what's important after the fact is to reiterate why you did this in the first place and why you were actually carrying out the patient's wishes. And so I think that gives families a lot of comfort in that the decision was made together. And I guess when patients talk about the loss of autonomy, what they like about MAID is that they have control in the setting, the timing, who's present, and that can be really important for both the patient and their families. And then that precludes a lot of sort of negative feelings after the fact.

 

MM: And in that vein, what would you recommend to patients or families who are considering medical assistance in dying?

 

BA: I think the best and easiest way is to speak to your physician. So whether that's your family physician, or your palliative care physician, or if you're in hospital, your internal medicine specialist, anyone that you see as your physician and who's caring for you in that moment in time would have this kind of information. As we said before, if it's not within their purview or their belief system to provide this kind of care, they would know how to access the care. And that's, what's most important, whether you're in a community setting, an institution in the community, or whether you're in a hospital, there are always teams available to provide this kind of information. So I would suggest speaking to your physician, your healthcare provider can direct you in the right path.

 

MM: This has been We Can Answer That. We've been talking to Dr. Beverly Adams, the senior associate dean of Education at the Cumming School of Medicine about the difficult topic of medical assistance in dying. You can subscribe to We Can Answer That on Apple, Google, or Spotify, or by visiting ucalgary.ca/podcasts. Follow our social channels to see which one of our experts will be featured in our next episode and to send us any questions you'd like them to answer. We Can Answer That is a production of the University of Calgary. Thanks for listening.

 

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