Some Ontario residents who were approved for medical assistance in dying (MAID) in 2023 were not offered supports that may have relieved their suffering, three new reports from Ontario’s chief coroner’s office say.
The reports indicate a lack of housing, chronic pain and histories of mental illness influenced some individuals to request MAID.
The reports were written by the chief coroner’s office on behalf of the MAID Death Review Committee, a 16-person committee formed in January. The committee — which includes medical professionals, social workers, ethicists, lawyers and disability experts — studies MAID trends identified by a team of nurse practitioners who review every MAID death in Ontario.
The reports indicate there were 4,644 MAID deaths in Ontario in 2023. Of those, 116 — 2.5 per cent — were cases where the person’s death was not reasonably foreseeable, a process known as Track 2 MAID.
The reports include summaries of six different Track 2 MAID deaths in Ontario that occurred over many years, says Dr. Dick Huyer, Ontario’s chief coroner. Not all committee members agreed these individuals should have been eligible for MAID.
In some cases, people were approved for MAID even though MAID assessors were not completely sure what medical conditions they had or, in complex cases, which conditions had prompted the MAID request. Most committee members said a conclusive diagnosis was not needed to show an individual was eligible for MAID — although they said there needs to be evidence MAID assessors considered all possible diagnoses.
One of the six profiled cases involved a father in his 40s who sought MAID less than two years after becoming a quadriplegic. The man was unable to return home with supports because of his complex medical needs.
Another involved a man in his 80s who had chronic back pain and a diagnosed psychiatric disorder. A third involved a man in his 40s who had severe gastric ulcers and a history of mental illness and suicidal ideation. The man had attempted suicide a year before he got MAID.
And another involved a man with inflammatory bowel disease who had a history of suicidality and alcohol and opioid addictions. During a psychiatric assessment, a psychiatrist asked if he had considered MAID and gave him information about it.
Many committee members expressed concern about the role mental health problems played in this man’s decision to pursue MAID. Some noted he may have benefited from “greater consideration of social and mental health supports.”
Mental illness
Legally, people who are approved for Track 2 MAID must be informed of supports — including disability and community supports, counselling and palliative care — that could relieve their suffering.
But data indicate this does not always happen.
In 2023, nearly 90 per cent of people in Track 2 cases were offered medical support to relieve their suffering, the reports say. But disability and mental health supports were each only offered in 41 per cent of cases. Counselling was offered in 35 per cent of cases. And community supports — including housing or income supports — were offered in 24 per cent of cases.
Social workers were consulted in nearly one per cent of Track 2 cases in 2023, versus three per cent of Track 1 cases. Track 1 MAID is available to individuals suffering from incurable illnesses, diseases or disabilities whose death is reasonably foreseeable.
In another case, a woman who could not find appropriate housing due to multiple medical chemical sensitivities was approved for MAID. Committee members could not agree on whether she should have qualified.
When a person requests MAID under Track 2, the law says they must be assessed by an expert in the condition that is causing their suffering. According to one report, this expertise was not sought in 1.7 per cent of MAID Track 2 cases, raising “legislative concerns.”
Mental illness was a factor in most of the six cases profiled in the reports. Some individuals considered, or attempted, suicide before requesting MAID.
Psychiatric expertise was sought in only 5.2 per cent of Track 2 MAID cases in 2023, the reports say.
‘Improve MAID practices’
According to the reports, “only a small number of MAID deaths in Ontario have identified concerns.”
Huyer said the coroner’s office has “consulted with the police” around some MAID deaths, but has not notified the police about any criminal concerns related to MAID deaths.
The reports are intended to cause reflection and hopefully improve MAID practices in Ontario, Huyer said.
The committee made several recommendations to the federal and provincial governments, various professional regulatory bodies and the Canadian Association of MAID Assessors and Providers.
Each organization is asked to “consider” the reports’ findings. But the coroner’s office cannot mandate that any group take specific actions.
“We can’t force implementation,” Huyer said. “We have no authority to do that.”
The reports note that, in many respects, the laws around MAID Track 2 are clearly followed.
But many members of the MAID Death Review Committee said there needs to be a “paradigm shift” when assessing people for MAID. Instead of focusing mainly on making sure legislative requirements are met, assessors should prioritize caring for patients.
This may mean considering patients’ socioeconomic standing and cultural background, including if they have a disability and how it impacts their social interactions. It may mean involving their family or reaching out to experts from various disciplines, not just medicine.
David Shannon, a lawyer and member of the committee, said he supports the creation of an interdisciplinary committee that reviews MAID Track 2 requests before approval. This committee could determine if the request is “coming from a time of desperation or incidental pain,” he said.
Shannon, who became paralyzed by a spinal cord injury 43 years ago, says he is concerned people with disabilities can be approved for MAID faster than they can be approved for financial supports or wheelchairs.
“The priorities are backwards.”
Shannon said he was encouraged by the parts of the reports that discuss the importance of MAID assessors considering the impact of disability and seeking input from people with disabilities.
“I thought that was extremely respectful of the disability community in an extremely difficult subject area with, obviously, often polarized, polarized perspectives,” he said.
Another committee member, Dr. Donna Stewart, a psychiatrist and professor at the University of Toronto, said in an email that the reports are “useful to identify the small numbers of cases that do not illustrate best practice and in so doing generate suggestions [and] recommendations to make MAID safer, better and more accountable for all Canadians, as well as MAID practitioners.”
Huyer said the total number of MAID deaths for 2023 in the province should be released soon. The MAID Death Review Committee will also be releasing a report later this year about the waiver of final consent for MAID in Track 1 situations.
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