MJM MedTalks
Medical Assistance in Dying (MAiD) Part 2

0008 MS: The McGill Journal of Medicine MedTalks is a podcast series where members of the McGill community and beyond are interviewed on topics related to career, research and advocacy. My name is Masha Samuel, I'm a Master's student at McGill University, and in this two-part episode, we’ll be exploring medical assistance in dying or MAiD from the perspective of Canadian Healthcare. These episodes touch on topics of mental illness, death and suicide, and we understand these subjects may be distressing for some audience members. So, please listen to these episodes with care, and if you need support, consider reaching out to a mental health professional. MAiD is defined as the process that allows any eligible individual to receive assistance from a medical practitioner in ending their life, permitted by the Criminal Code of Canada to take place under specific circumstances. In this episode, we'll explore the conversation surrounding the inclusion of mental illness as the sole reason for accessing MAiD. The Canadian government recognizes that mental illness can cause the same level of suffering as a physical illness and planned to further extend the eligibility criteria to MAiD. However, the government introduced legislation to delay this expansion by three years, stating that our health system is not yet ready to safely implement this change. This decision has garnered both support and opposition. Joining us again are Blair and Nicky. So there seems to be an implicit paradox when it comes to mental illness and MAiD, we accept that mental illness can cause the same level of suffering as a physical illness yet with MAiD mental physical health exist in different legal categories. So, I'd like to ask you, from your understanding of medicine, what is the difference between a mental and a physical illness? And why does the conversation on MAiD shift when we talk about mental health as the sole reason for requesting MAiD?

0208 BCS: So, and I can certainly take a crack at that, and I think it’s important to look at this question in terms of the evolution of the law and the evolution of MAiD. And I think that may be, that may be your framework. So firstly, as a clinician, I'll be very happy to say that I absolutely think there is no difference whatsoever between suffering, decline of function, that may come from a physical illness, or from a mental illness and a very truly deeply believe that there are people who suffer from mental illness who are well followed by mental health, who have a degree of psychological, existential and functional decline that is akin and no different in any way, shape, or form from that, that comes from physical illness. But I think you need to look at the evolution to try to understand why the legal system treats it differently. So, if you go back to 2015 and sort of, if you look at how the legislature started to put together MAiD in response to the Carter Decision. So, the Carter Decision’s landmark Supreme Court decision, that sort of opened up the juris prudence to allow jurisdictions to administer MAiD, and then you look at what the courts sort of said, the courts very clearly defined a grievous and irremediable condition that led to suffering, and they left it at that. And they didn't, they left it very, very, very open. And what's legislature done in the subvening years, is they've put up what I like to kind of refer to as a couple of straw man things. Okay, so what's the first thing they did? The first thing they did is they limited medical aid and dying to people who had a, either in Quebec at the end of life, the fin de vie criteria that came out in the beginning and then the rest of Canada went out with reasonably foreseeable natural death. Um, and I want to be clear that was nowhere in the Carter Decision. Nowhere did the Supreme Court Justices say that that was a requirement, but what was that? That was a strawman. That was saying, hey listen this is new, okay, this is brand spanking new in healthcare. Everybody across the spectrum is not yet ready for this. We need to work out the logistics, who's going to do the assessments? How do we put the safeguards in? How do we review them? And I think a lot of it also was a move by our legislature to increase palatability, okay? So you're bringing this new thing in and what did that first restriction on end of life do? It sort went to the society to say, hey, listen, we're going open this door and all we're doing with these cases is not changing the outcome, their death is inevitable. Their death is if it was, you know, in Quebec, it was fin de vie, three to six months, maybe a year, depending on how you want to interpret that law, naturally, foreseeable death in the rest of Canada. So all we're doing is sort of changing the time scale, not the outcome, all right? And they did that knowing full well that as soon they deposited that, people were going to challenge that in court, and they did, right? And so, in Quebec, the Truchon Decision took it to the Superior Court and said, listen, that's not fair. I don't have a reasonably foreseeable death, I have the same degree of suffering. And so, you then the next sort of, you know strawman to fall was the prohibition on that for, for physical illness that didn't have a reasonably foreseeable death. And so, what did the legislature do? They sort of went back and said, all right, it's been going okay for the people who had a reasonably foreseeable death, how do we then build the next level of safeguards in to expand this with different patient population? And so, as Nicky was referring to the 90-day wait period, okay. The inability to have the waiver of final consent. The need for physicians to consult an expert, if you were not an expert in that disease, we're all put in as safeguards to ensure that we didn't have inappropriate expansion for our track two. And so, I think you really need to understand that I don't think the lack of inclusion of sole mental illness as an indication is inherently paradoxic, I think it reflects the natural evolution, okay? And I think that is the next big giant mountain that our, our legal colleagues, our ethics colleagues, our healthcare colleagues, they're going to tolerate because I think there's going to be huge challenges in expanding. I think everybody on this side of things, I think most MAiD providers and assessors, I think the general public has broad support for it, my read on the legislature and the legal communities that everyone's on board with it. It's a matter of figuring out how to do it. And so, I don't necessarily think there's a paradox, I think it's really just the natural evolution of things. Let’s start with the low hanging fruit, the easy things, let's build the network where everybody agrees, okay? This seems to work. Okay, who's next? And I fully, my heart breaks for people who are waiting for this to come through truly and deeply. I ache for those people who feel that they should be able to have it now and I can share with you that I looked after many people who ultimately would have been eligible for track two and I had to say no in the early years and that was the hardest thing I've done as a MAiD physician. Look, somebody in the eyes and go yeah, let's wait out these court challenges. And so, really, as a physician, my heart really does ache those people who feel their mental illness is causing the degree of suffering akin, an identical and exactly the same. Just, our system isn't yet ready for it, and we don't have the safeguards, and I don't think we have that. And so that's, that's the paradox. I think it's just really more systemic rather than any fundamental difference between the two.

0726 VF: One of the best quotes I heard on this is a bit like yeah, you don't, you don't fix the airplane while it's flying. So, there's an inherent danger in creating a law before we have the safeguards to sort of, I think respect the autonomy of people who are suffering while protecting the vulnerable from having a death too soon, which is one of the worst fates imaginable. So, yeah, I think, I think proceeding cautiously and, and one thing that's also interesting is in Quebec, is a bit as opposed to Carter in Canada, is MAiD was a democratic process, right? Like MAiD came through public consultation with the public town halls with stakeholders, with physician groups with, you know, disability rights advocacy groups with mass consultation, and there was sort of this public wave of support in 2015, where MAiD passed, like, in a show of bipartisan support that this is something Quebecers wanted with the understanding of the end of life criteria, being included in that. So, I this talk about enlarging MAiD and sort of moving it forward to include sort of different categories, whether it's mental illness, or mature minors, or what have you, it's important to go back to that foundation and sort of look at a Quebec society as a whole and is this something we agree as sort of the good and the right thing to be offering people at this point in time.

0853 MS: Out of your colleagues who currently provide MAiD or support patients and their families through MAiD, do you, how many of them do you think would continue to feel comfortable continuing their work, if and when MAiD is legalized for solely mental health reasons?

0909 BCS: From the, from the assessors side of things, so the physicians in the NPs, I think it's really going to come down to what the nuts and bolts are. And I think the key element to it and what the trepidation I'll share with you honestly, I'm, you know, I have, as I said in my sort earlier answer, I have no conceptual concerns whatsoever I mean, suffering is suffering, diseases disease, mental illnesses is as real, as debilitating as physical illness. I think the major concern is going to be, who is making those decisions of when is a disease refractory?How many lines of antidepressant medications, or anti-psychotics, or ancillary therapy, ketamine and electroconvulsive? Like when has the patient reached that point and I think if you look at the evolution of the law, right, so with the reasonably foreseeable death criteria, there was no requirement to consult a specialist, I mean, a doctor’s a doctor. I mean, many of these assessors are family physicians, a few of us are specialists. And you know, when you see someone dying of cancer, it's part and parcel of what we as physicians and nurse practitioners, we, we see that and so we know what that is and then when track two came in and we started including you know a couple of rarer neurological conditions things like spinal muscular atrophy or certain other neurological, conditions, many physicians don't have an expertise don't know the natural evolution of this condition. Can it bring out the symptoms that the patient is referring to? And so, the legislature said, you must speak to an expert, whether it's a neurologist, a geneticist, you know, physiatrist, if you don't have an expertise in that, in that domain, and that's where things are going to get, really, really tricky for mental health. Because I will be the first person to tell you, I don't know diddly squat about the diagnosis and management of severe depression. I just don’t, right? And the problem is that you know severe depression or bipolar disorder or any of the diseases that may lead to advanced functional decline are real and prevalent and the cases where in they are so refractory that they would lead to decline in function, leading to someone making a very reasonable request, that's going require expertise of mental health professionals. And I think that a lot of the onus is going to get put on our, our psychiatry colleagues, psychology, our mental health nurses, our OTs and our, everybody. And so, I think that's where the trepidation is. I think if we as MAiD assessors see a well-founded process whereby you know, there's a mental health expertise saying, yes, this patient has, for example severe depression, they have failed four lines of antidepressants. They've had x amount electroconvulsive therapy. We've tried, you know ketamine, we've done psilocybin. We've, we've tried it all and can really say, yes they have the capacity. This request is not a manifestation of their disease, you know, sort of, they don't want to die. This is not, this is not an attempt to not live, it's an attempt to not suffer and I, you know, my concern is that at least many of these assessors now, not being from a mental health background, I would not know that. Like, if you came to me and said, hi, I have severe depression, I'd like, MAiD I would go, I would be out of my depths, but I think if the legislature and I know this is what they're doing behind the scenes, can put together a pathway whereby experts from mental health can do that and say, yes, yes, Dr. Schwartz, Blair, listen, I've set this assessment and from a mental health standpoint I'm comfortable to you know, Mr. Jones, fake name, is apt. Truly has depression, has been refractory for x amount of time and in my expertise as a mental health expert, I have nothing I can offer to make him better. And his request is really based on a desire to not live like this rather than he just wants to die. Then I personally, and I think many of my colleagues would be okay with that, because I think the majority of physicians, you know, don't see a paradox or a lack of equivalency in mental and illness. I think it's just the safeguards that have a us little scared.

1311 VF: I totally agree with what Blair's saying and I think there's, you know, to not, to not do the mental health essentialism too much, we see it also with physical illness when we look at what providers are willing to do, I, you know, just with the track two cases, for instance, a lot of my MAiD providers will agree to do track one, but are not comfortable doing track two for variety of reasons, because they're more time intensive, because they require more specialization, sometimes because they're not morally comfortable, it depends, a variety of reasons. But so, you have this much smaller pool of people willing to do track two. And that's something we're already facing. So, I, I imagine it'll be sort of a bit the same thing. Not only will people need the training, the preparation, the resources and sort of safeguards set up and the colleagues with the expertise. But, sort of identifying the MAiD providers that are also going to want to be involved, and what that will look like.

1402 MS: An argument in opposition to MAiD, is that suicidality can be a symptom of some mental illnesses and therefore should not be the reason someone receives MAiD. So I’d like to ask you, is there a difference between the term, assisted suicide and assisted dying. Are they different, is this the same thing? And how do we navigate the dual reality of suicide as a symptom of the illness and as part of the solution that we are providing?

1431 BCS: I think there are two issues to parse out here. So, I mean first off there's just the lexicon, okay. So medical aid and dying and physician or healthcare provider assisted suicide from a pure lexicon standpoint are two separate things. So physician or healthcare associated or healthcare provider assisted suicide would basically be you assess the person is eligible, you provide them with medications that in that dose would be considered lethal. They go home. They take it in their private setting and what will be will be. Whereas really in Quebec that is not legal, right? So, while physicians assisted suicide is legal in many jurisdictions, it's the dominant pathway in Europe, for example. It is legal in the rest of Canada. It is not currently practising Quebec. What we do here is medical aid in dying. And so, what that means is that at the chosen time, the procedure the physician meets with the patient or nurse practitioner and administers a cocktail of medications to bring about their death. So, the first major difference between medical aid in dying and physician assisted suicide is one of them is a self-administration and one is a is an external administration by a healthcare provider. Um I think the important thing to get to and what you're sort of getting at is yes you know unfortunately a manifestation of many people who have chronic psychiatric illness is suicide or suicidal type gestures and I think the concern then comes in how much is you know, is are, we just giving them an avenue by which to accomplish something that maybe a manifestation of their psychiatric disease as opposed to a genuine desire of, I can't live like this and very honestly as an internal medicine critical care doctor, how to make that distinguishment, I can't do, but think it's important to understand that you know that, that a suicidal gesture or suicidal attempt can both be, can actually be, can be two separate things, right? It may be a manifestation of a poorly controlled psychiatric illness, or it may equally be a self-desire to no longer live in that particular fashion. And I don't think that the two of them negate each other. I mean, I've had many people, I'm not sure Nicky, your experience, I've had many people who ultimately, you know, had had severe organic illness and in a moment of clear lucidity in the absence mental illness, looked at their life and said, nuh-uh, and made a suicidal attempt in either were, were not successful. And, you know, when you speak to them in the MAiD process and you say it's like, so listen what was the deal? It was really very much a desire to that, and are there patients with mental illness in whom they're suicidal gesture is or their desire to no longer live is purely driven by suffering and not ability to tolerate the function as opposed to a manifestation? And the answer is probably, and how to determine or how to discern between the two, I doff my hat ahead of time to mental health colleagues. I do not envy them. I really don't know how they are going to tease that out, but I really do believe that there is a population of people in whom they have a mental illness and their desire to no longer continue to live like that is no different than a track one. But it is a, it is a concerning thing. And I think that's really where a lot of the people's trepidation comes from, right? You know, will MAiD just be an easy out of you know, okay, I've, you know, I, I have a chronic suicidality that can be a manifestation of variety mental illness and now I have this pathway that's going to, that's going to make quote, unquote, suicide, easy. I can't believe I said that out loud. And of course suicide is horrible. And, you know, absolutely is something that needs to have increased infrastructure to help with prevention. But I don't think the two are mutually exclusive. I don’t think because suicide, suicidality, suicidal gestures, can be a manifestation of mental illness, should be a complete prohibition. But how you separate those two? I do not envy my mental health colleagues who are going to have to answer this question sooner rather than later.

1828 VF: I agree with, with everything Blair said, I think conceptually it's, it's, it’s really challenging and that's why there's so many smart brains thinking about this and disagreeing about it and arguing about it and trying to sort it out. Practically, I think on the ground, some simple rules I keep my for myself when I'm trying to distinguish MAiD from suicidality or looking at patients, it's again, MAiD is a very circumscribed act with rigorous criteria that apply, that has evaluations, that is a process that takes place over time. So things that would be red flags for me when I'm looking at sort of maybe thinking about suicidality versus MAiD, you know, impulsivity is there, is there a pattern? Has this been, request been consistent? Is it coming at a point of crisis? Is it consistent with the person's life narrative or is it something sort of disruptive? Sort of looking at all those things, sort of collectively as a whole, and then sort evaluating that, I think it's helpful because we do that now. We'll see, we'll see patients, who have had suicidal gestures or will see people who are requesting MAiD and telling us, if you don't provide me with MAiD, you know, then I'll kill myself. So that's, that's not an unknown thing but think it's like really looking at, is it reasoned? Is it well informed?Is it somebody who knows about all their options? Is it somebody who's been thinking about this for a long time? Is there, like an absence of ambiguity? Is it an exceptional act of last resort? So all these things sort of, we, we look at presently and, and look at and work through and, and we go slowly, you know, MAiD is not a quick thing, it's funny. Sometimes we still have patients that come out, come in and they'll be like I want it today, you know, give me the MAiD. Again, it takes a while. And if we have difficult cases, if we have these grey cases, if we have these intersections sometimes, it might require multiple assessments. We might need to see that trend over time. We might need to consult experts within psychiatry and psychology and move to sorts, whatever it is you know, to get that full picture to make sure I think fundamentally what it comes down to me is, right decision, right patient, at the right time.

2039 MS: So the Canadian government has stated that our healthcare system needs more time to implement safeguards before we can proceed in providing MAiD for solely mental health. From your perspective, what is it that Canadian healthcare needs to prepare for this transition?

2055 BCS: So, as Nicky said, I'm really grateful and thankful that I'm not one of the people who has to sit on the committee to try to figure these, these other things out. But I, I think the real big bulk is going to be the, the medical expertise. It's going to really be on our colleagues for mental health. Like I said before, the psychiatrist, psychologist, occupational therapists because the biggest concern is really on eligibility, aptitude. And as you sort of said, how do you parse out the difference between, this is a manifestation of their disease, or this is a well thought out, consistent, I can't continue to live like that. And I think one of the things to be aware about, and just you have to be practical, open up a newspaper and read about our access to mental health services, okay? Right now in 2024, the wait list to see a mental health professional on a good day, is way longer than it should be. Right? And we understand that there is a large swath of the population who probably would benefit from mental health professionals. And so, one concern that I have, and I think you need to be pragmatic about it, is that, you know, when this becomes legal and it will, I have genuine concerns about access because I think you're going to see a similar process amongst the mental health professional community. As we saw in the medical community at large, right? Initially, there was a conception as Nicky was saying in the opening that every doctor was just going to do this for the longstanding patients. And what do we seen? It's a minority of physicians who are willing to administer and provide MAiD, and that's okay. If you get the same issue with the mental health professionals, right? If it then becomes a very small percentage of psychologists and psychiatrists and psychiatric OTs, etcetera, who are willing to do these assessments, I really worry that we may over tax an already underfunded, understaffed system and I have genuine concerns about access. And so, it's clear there’s going be a huge burden put on our mental health colleagues, who are already, you know, holding the, holding the forts barely and, and I had genuine, really very genuine concerns about what this expansion, that should happen, let's be very clear. I'm not saying it shouldn't happen. It should. It absolutely, people with mental illness do have the right to be assessed. Do have the right to be evaluated and ensure, as Nicky said, you know, the right procedure for the right patient. I have just a very real concern of what's going to happen to our very fragile mental health infrastructure when this happens.

2331 MS: I have definitely heard the argument brought up that we are, we are, we are limited in how many mental resources we can provide to people currently and by making, your sort of entering muddy territory when you make MAiD for mental health, exclusively, accessible, readily accessible to people as an option sometimes maybe even more accessible than other mental health services, which is definitely troublesome.

2359 BCS: Absolutely. And to parlé on that and put it sort of into the non-metal health, I mean one of the major concerns with medical aid in dying, you know, came into play for track one and then track two was that, you know, was lack of access to palliative care, in the case of track one or special adapted services for people with neurological disorders and handicaps, was MAiD going to be the easy way out? Was it going to be, you know, I can't get seen by a palliative care physician ergo, well, you know, the MAiD doc right over there or, you I can't get a wheelchair, or a ramp, or an electrical wheelchair for my, for my home. So, so, MAiD is going to be right there and I think, you know, while certainly if you look in the media there are cases, isolated cases that were that were reported, were that was the case and then glad to say it's isolated, I still think one is too many, let's be very, very clear. I mean if people have to record to MAiD because they couldn't get the other services they want that, that's a failure of the system, and I think that's a genuine fear, right? If you have someone who has a horrible mental illness that they can’t get care for, and there’s easier access to MAiD, is that going to be the easy pathway out? And, you know my only hope, and you know I have faith in the legislature, I think you have to, right and as challenging and under-resourced as our healthcare system is, they’re going to have to put in safeguards. And I think that’s going to lead to problems of access. And I think it's certainly going to lead to barriers and delays and challenges, but I think, I hope, I'm confident that our legislators and you know, our, our Bar Association, the Order of Nurses, pharmacists and Colleges are going to insist that there is a pathway that is going to prevent MAiD from being the easy access to supplement an underfunded problem. And my only hope would be, you know, when Bill respecting end of life care that Nicky was referring to came in and it was a fascinating example in Quebec literature, it was legislature, excuse me, it was one of the few cases where a bill fell from the previous government. So, it was a PQ funded bill that actually dropped in the legislature when that government was voted out and it was resurrected by the oncoming liberal government, and they actually invited the Bill proponent across the floor when that Bill passed, but inherent in the Bill, you know, everyone talks about it as a law that brought in medical aid in dying. But what they forget about was that enshrined in that law were additional support and infrastructure for palliative care, right? And so that the fact of saying yeah, we're going to bring in medical aid and dying but we're also going to insist on enhanced access to home palliative care, and hospice care, and in hospital palliative care. And so, I would hope that if you're going to see the same sort of evolution, if this is going to be an option for mental illness, I'd like to see, and maybe this is now me, you know, living a pipe dream, that tied in with that is some sort of legislation with accompanied funding and resources to say, we're going to do this in to help our mental health system do that, we're going to expand resources. Now again that may just be me living a dream but I think that that has to happen.

2707 MS: Yeah, I think it would be a wonderful reality where you know when and if this comes to reality that also in parallel with that, we have additional mental health services in society. I think that would be, that would be wonderful. Nicky, anything that you'd to contribute?

2725 NF: Oh no, I agree 100% with what's been said already. I think it's going to be incredibly challenging to put these things in place. I guess if I pivot a little bit, one thing that I think that's interesting is a little bit is while we're waiting for the hypothetical of MAiD for mental illness, it's important to remember that, there's big changes already coming for us with the legalization of Advanced Medical Directives for MAiD, for, for people with dementia or Alzheimer's to be able to say, you know, I would want MAiD in five years in the future when, if my condition becomes such that I can't recognize my kids, etcetera. So that was legalized in Quebec last summer 2023. They're in the process right now of sort of doing what we're talking about for mental illness. Putting the pieces is in place so that we can actualize it. They're saying it's going to come into effect in 2025. I see that being fraught with challenges. It's maybe not as, I think, there’s a lot more, in a way it’s less controversial than mental illness, but it is going to present some challenges. So, I'm sort of interested to see how that's going to go, as a pragmatic, front facing challenge for us right now. And I wonder too, when we talk about MAiD and introducing change, if having all these changes sort of come on top of the other, if it's going to be a lot for sort of practitioners and health care providers on the ground, so sort of absorb all at once, but anyways. Yeah, I just want to sort of highlight that that is, that is coming for us and it's coming for us soon. Though again, we'll see because there's disagreements between the provinces and the federal government about whether or not the feds will open the doors to that but in Quebec, it's ostensibly coming for us.

2905 BCS: Yeah, Blair any, any thoughts on Advanced Medical Directives? I know, you’d mentioned that earlier so, I'd love hear your thoughts.

BCS 2914: 100%. And again you know what you're seeing is is is expansion. And this is as I kind of referred to the ongoing strawman of you know, put something up and knock it down and continue to expand and and I think it'll be an interesting exercise to see the safeguards that are put into place. You know, I have some concerns because, you know, one of the hallmarks of medical aid in dying, really one of the things that I always say when I'm seeing my patients is this is about autonomy. This is the ultimate expression of patient autonomy, of their understanding of their current existence and looking at around, at themselves and saying nope. Now, what we're doing is sort of asking you to predict in the future, what you would find intolerable and that raises some interesting questions for me. You know, for example, patients will often look at me when I'm doing this medical aid in dying assessment, say Dr. Schwartz, if you were in my position, would you be making this request? And my answer? And this is not me playing with words, as I don't know, because I'm not in your position, right? I don't know what I would do if I had end-stage emphysema or I had pancreatic cancer and I was bed bound, I don't know, I'd like think I would know, but I always say nobody but the person in the body in that bed in that chair knows whether or not life in that current state is intolerable. And I think it is difficult to predict what one would accept in the future and my, my cautionary tale and example is always, I've had lots of people tell me. Oh, you know I would never, would never ever want to live after having a stroke, you if I can't have, you know, function of all four of my limbs and speak clearly, that's, that would not be a life worth living. And then meet many people in my work and Intensive Care Unit who have cerebral hemorrhage and have that and have that and say, well, you know what, listen, not amazing but as it turns out, like I'm actually not so bad, now that I, now that I'm here, not not tremendous so I do have worries about people predicting the kinds of things that they wouldn't accept in the future until they actually get there. And I think there are very, very significant concerns about safeguarding in terms and, you if you're no competent to make the request, it's one thing if you start becoming a little bit, you know, a bit dementia but you say, oh yeah, no listen, I, you know, today I, you know, forgot the pot on the stove and you know, that's not a quality of life that can live with and they can be, you know, very apt. But when you become inapt and many people are sort of saying, listen, now I want this in the event that I become inapt, I can no longer recognize my grandkids, therefore, the person I have designated, my son, my spouse, I would want them to raise the flag and and bring it up. I have concerns in terms of how that's going to be, going to be played out. And again, as a frontline MAiD partitioner, I'm always really happy that I don't have to sit those committees because I'm not sure I'm smart enough to figure these things out, but it'll be very interesting as Nicky's sort of saying to see what the powers that be put place is safeguards because I think many of the safeguards that may be applicable to, to this dossier can be used in the future in terms of, in terms mental illness. But you know, we're seeing expansion. I think the MAiD practitioners were clearly supporting of the concept, but think as we expand and enlarge, more and more concerns occur, and I'm really happy that in Canada, and Quebec that we're doing this in a piecemeal fashion, that we're taking the time and they say, 2025 they want wait to 2026, I'm okay with that if it means we're going to do this in a safe fashion and my heart does ache those who are sort not able access it until that time. But I think as a society we need to really be sure that we are comfortable with what the process is. Because if we go to a level where it's no longer comfortable, where we've gone too far, we've, we've quote, unquote gone rogue it's going to undermine the entire process. So, we really need to tread lightly, moving forward.

3303 MS: What advice do you have for healthcare professionals who are interested in getting involved in this field? Whether in providing MAiD, supporting patients or supporting patients through the process, or end life care as a whole? What, what could you tell those young healthcare professionals?

33:20 BCS: I will say this, you know, as a, my non-MAiD practice, I’m a general internist, an intensivist, I look after people in hospital and in the Intensive Care Unit in some of the most critical moments, and support them through really trying times. And I will say, since I started to do MAiD, they rank amongst my most meaningful patient interactions. You meet amazing people, you hear amazing stories. It really does take a certain type of persona. I always sort of teach this to my residents and students, there's a certain sort of personality archetype that has the insight to look inside and go, this isn't for me, and you can you really get to have amazing interactions. It is some of the most rewarding work that I've done. I have, you know, I had that one-week trepidation of, should do this? And when I finally sent the email to the DPS saying, sign me up as the MAiD Doc, I have no regrets whatsoever, it has been a tremendously fulfilling component. I've laughed with patients, I've laughed with families. I've given more hugs in this aspect of my medical practice than in others, it is tremendously rewarding, it's not for everybody. And I think it's important to understand for young healthcare workers, you don't need to be okay with this. This doesn't need to be something that you have to do. And you need understand as we said earlier that, it's part of the patchwork and quiltwork of Canadian Healthcare and people have a right for it in a right to be referred, it's not for everybody. But if it's something that you could see yourself doing, it is tremendously rewarding and I would just encourage you to reach out to, you know, whether it's your nurse, MAiD nurses, MAiD physicians or whatever, and just sort of you know, get exposure. Patients are very, very willing to have medical students and nursing students and NP students and residents and other faculty come. I often bring a trainee with me just to see what the, what process is like, and, and explore it. And so certainly feel free to reach out and, and see if that's something you'd be interested in because it is tremendously, tremendously rewarding. I mean, I, I walk out of each one of them a little bit fuller as a human being because it really is quite an amazing experience.

3528 MS: On that same note, one more question for you Blair, what are some of the most important qualities to have as a MAiD provider?

3537 BCS: Not one is good about speaking about myself but I'll sort of speak generally. I think you just need to be a good listener and a good communicator. And you need to actually, like care. It is, you know, truly the patients get a tremendous relief by being assessed, just simply knowing you're there, knowing that this option is there, knowing that there’s a way out from their suffering and just be a good communicator and just and just sit down and just look at them. Okay, and, and talk and the MAiD assessments, it's not a medical procedure, I'm not doing a structured interview. I just literally sit down on a chair at their level and look at them and I talk. And so, you know, what are you looking for? You're looking for, you know, firstly someone who's comfortable with the concept of MAiD and then needs to be comfortable, at least if you're going to be a first MAiD assessor and MAiD practitioner, you need to be very comfortable with the fact that you are going to give medicines to someone, and they are going to go to sleep and die. And you need to be okay with that. And in all honesty, it's hard to know that you will be until you go ahead and do it until you go ahead and see it. But really, the biggest thing is that you just need to care. This is the ultimate ultimate relationship and it's the ultimate form of caring and it's the ultimate form of medicine. And so, if you're someone who can listen and talk and be compassionate and sometimes, although it’s hard to tell from how much I've spoken on the podcast, not say anything and just listen for 10 minutes sometimes and just sit there and go, mhm, that's the kind of thing you need to do to do MAiD.

3707 MS: And Nicky, similar, same question for you. Do you have any advice for healthcare professionals who are interested in this field, are interested in a similar role that you have?

3720 VF: Hard to improve on Blair’s answer. I think he highlighted a lot of the good points. I always find it a bit funny when I tell people what I do, the most common response I get is like oh, that's so sad. That must be so hard, and it and sometimes it is, sometimes it's challenging, but as Blair said, it's, it's infinitely rewarding and like profound, and it can be pleasurable and you can laugh with people and you share. And it's such, such a privilege to be able to accompany people in these positions. So, so it's, it's not sad and depressing. It's a wonderful opportunity to be part of patients and families lives. So, I really think that and all the, most of the docs and nurses, mostly the docs I talked to say exactly what Blair said, it's, it's one of the most rewarding parts of my career. It's the time I get to sit down and listen and hear somebody's life story and understand that, and that is powerful. For people who are interested, be curious, as Blair said, listen, we spend far too much time talking to patients, sit down on a chair, pull up a chair, sit down, spend the 10 minutes. For med students that are, maybe don't have a lot of experience, don't be scared to talk about death and dying. If, people will be ready. You'll find the words. Start. Listen. Be open. I guess the last thing I would say is, we do spend a of time talking about MAiD, and I think MAiD is incredibly important and it's, you know, controversial and it's, it's a lot of things and now it's, you a right to access healthcare, but we need to remember that again, it's like eight percent of our population that's accessing MAiD and 92% are not, they’re receiving palliative care. They're dying at home. So, if it's something you're curious about, be curious about it, sort of globally. What is death and dying mean? What relieving suffering means? Sort of look into that. And on a more practical level, there's lots of resources out there for medical aid and dying for people who are interested in it. CAMAP, the Canadian Association of MAiD Assessors and Providers is one of the sort of I guess foremost groups in Canada right now and they provide a lot of training. There's stuff online, there’s stuff that's freely accessible. There's a lot of resources through them. So that's also a place to start to sort of look stuff up, if you're interested in MAiD.

3956 MS: Thank you to Blair and Nicky for joining us on this episode of MedTalks. This podcast was edited and produced by the MJM podcast team, feel free to reach out to us on Twitter or Instagram @mcgilljmed or by email, we would love to have your feedback.