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A doctor at Princess Margaret Cancer Centre is supporting the development of a curriculum to help health care professionals navigate the complex and ever-evolving medical assistance in dying (MAID) program.
While MAID was legalized in 2016, the legislation has since been amended and expanded, making it more challenging for physicians, who receive limited training as medical students in how to discuss MAID with patients, and how to implement the legislation.
"From one day to the next, it became something that doctors and nurse practitioners needed to be able to provide to patients who requested it – but nobody learned how to do this in medical or nursing school," says Dr. Madeline Li, psychiatrist and clinician scientist at the Princess Margaret.
Dr. Li says this created a need for clear training for medical students and providers alike. She hopes the creation of a standardized, national curriculum will ensure every health care professional in Canada is trained in how to provide access to patients who request MAID in a safe and appropriate way, and how to navigate difficult conversations.
Dr. Li is one of three co-Leads on the project, along with Dr. Stefanie Green, a family physician in Victoria who is President of the Canadian Association of MAID Assessors and Providers (CAMAP), and Dr. Gord Gubitz, a neurologist with Nova Scotia Health in Halifax.
MAID was first offered to patients with terminal illnesses such as cancer, following a decision by the Supreme Court of Canada that found prohibiting assisted dying infringed on patients' constitutional rights. Patients had to have a “grievous and irremediable" condition, be in an advanced state of decline, and undergoing intolerable suffering. Two assessors needed to confirm the request, and the patient had to be found to be capable to make the decision.
Last year, the federal government expanded eligibility to include Canadians who aren't dying imminently, removing the requirement that their death be "reasonably foreseeable." Patients whose death is not reasonably foreseeable must now either be assessed by professionals with expertise in their condition, or have one of their assessors consult with a professional who has the requisite expertise.
The number of MAID deaths has increased in Canada from about 1,000 in 2016 to more than 10,000 in 2021.
"The development of a curriculum is much needed, important work to ensure that health care providers in our country who are involved in MAID can have the competencies required to serve their patients," says Dr. Mark Bonta, Lead of the MAID program at UHN.
"This was something that was expected because it was legislated, but that expectation didn't come with any training or skills – and in my experience overseeing the program at UHN – this isn't something that's easy to do, and not something that clinicians are comfortable with."
Dr. Bonta explains that the team of UHN clinicians who volunteer their time to complete MAID assessments and interventions is made up of 22 physicians and nurse practitioners, which reflects the number of providers who are most comfortable with this field.
He hopes that a formal curriculum, once made available to all clinicians at UHN, will lead to a sizable increase in the number of clinicians comfortable with responding to requests for MAID.
The curriculum, being developed by the CAMAP consists of seven separate modules designed for existing healthcare providers, and all medical students and residents across the country.
The first module aims to normalize the practice in medicine, consisting of legislative background, history, ethics, and the role MAID plays in palliative care. The second module will teach providers how to converse with their patients about MAID, including the discussion of care goals, the severity of pain, and alternative options.
The third and fourth modules, with Dr. Li chairing the fourth, consists of general assessment and eligibility criteria, as well as a deep dive into complex assessments regarding the capacity and vulnerability of the patient. Similarly, modules five and six focus on the steps involved in providing MAID in both straight-forward and complex case scenarios.
Module seven, which is still being developed, is about navigating MAID for patients suffering solely from mental health disorders and mental health co-morbidities. Dr. Li says this module is particularly challenging.
MAID access widening next year
"If you have cancer, and on top of that, you're depressed, how do you determine which is driving the MAID request?" she says.
The federal government is widening access to MAID to include people with a mental health diagnosis as a sole criterion, effective in March 2023.
"Canada has not assessed or approved any cases like this before, so the question becomes: How do we safely assess patients with a mental health diagnosis for MAID?" Dr. Li says.
There is content embedded throughout all seven modules designed to help providers manage their own mental health in light of such emotionally charged work.
"Given how complex this environment is, the curriculum will really help to create a robust educational tool that will enable providers to administer MAID confidently," Dr. Bonta says.
"It's great that the CAMAP community has come together to create the tools to help people provide such a complex service."