An elderly Ontario woman had a medically assisted death hours after being approved for it, despite doctors’ concerns that her spouse’s caregiver burnout contributed to the request, a new Ontario chief coroner’s report says.
Before she was approved for medical assistance in dying (MAID), she was deemed ineligible for placement in a palliative care facility.
The woman, referred to as Mrs. B, is one of three people whose deaths are profiled in a recent report from Ontario’s MAID Death Review Committee. The committee reviews complex MAID cases in Ontario.
Their report, which is available upon request only, focuses on MAID deaths that occur the same day or day after a patient receives their MAID approval. It highlights debate among committee members about how quickly some patients receive MAID after being approved for it.
The report raises concerns that for some dying patients, MAID is more readily accessible than palliative care.
Many members of the committee “identified that barriers to accessing inpatient palliative or hospice care … was a likely factor contributing to the reason for [Mrs. B] accessing [MAID],” the report says.
Some committee members also raised concerns about MAID not being properly consented to, or being approved in some cases where patients could recover if given time, appropriate care and information about other care options.
However, MAID assessors and providers on the committee said, “same day or next day provisions are not inherently problematic.”
Palliative care
The report is one of the latest from Ontario’s MAID Death Review Committee, a 16-person committee made up of doctors, lawyers, social workers and MAID assessors and practitioners.
The committee reviews complex cases referred to it by a team of forensic nurses, which reviews every MAID death in Ontario to determine whether the law was followed.
In 2023, there were 65 same-day MAID deaths, and another 154 the day after a patient was deemed eligible.
Mrs. B’s MAID death occurred the same day two MAID assessors approved her for MAID as required by federal law.
The day before she died, Mrs. B — who experienced complications from an artery bypass surgery — met with a MAID assessor. During this assessment, Mrs. B said she no longer wanted MAID and instead wanted to continue at-home palliative care.
The next morning, Mrs. B and her spouse visited an emergency room. Doctors discharged Mrs. B after determining she was fine, but said her spouse had caregiver burnout.
Mrs. B’s doctor requested she be moved to palliative care because of caregiver burnout. The request was denied. Her spouse’s caregiver burnout was not enough to make Mrs. B eligible for palliative care.
Later that day, Mrs. B’s spouse called the provincial MAID coordination team and requested she have an urgent MAID assessment.
A new MAID assessor found Mrs. B eligible. The MAID assessor who saw Mrs. B the day before was contacted and expressed concerns about caregiver burnout. This assessor asked to meet with Mrs. B the next day. The MAID provider declined, saying Mrs. B’s case was urgent.
A third MAID assessor found Mrs. B eligible after a virtual assessment. Her MAID death occurred that evening.
“Some [committee] members expressed their concern that access to MAID was more easily organized and accessible in this circumstance than the previously requested and preferred option for end-of-life care,” the report says.
‘Further failure’
Canada’s original MAID law, passed in 2016, required a person to wait 10 days between requesting MAID and receiving it.
In 2021, Parliament removed this 10-day waiting period for people with reasonably foreseeable deaths, also known as Track 1 MAID. People without reasonably foreseeable deaths must wait a minimum of 90 days.
There are no additional eligibility criteria to determine if same-day or next-day MAID is appropriate.
The committee’s report raises concerns that some people receive Track 1 MAID even when their diagnosis is unclear and recovery could be possible.
The report profiles the case of Mr. A, a psychiatric patient in his 90s who received MAID a day after being approved.
Four months earlier, a MAID assessor had found Mr. A ineligible. Shortly thereafter, his spouse died and his alcohol use disorder relapsed, possibly due to grief.
He entered psychiatric care because of suicidal ideation, and while there, requested MAID. His previous MAID assessor now approved his request after a phone appointment.
A second assessor approved him for MAID after a virtual assessment where Mr. A complained of shortness of breath and poor energy. The assessor “presumptuously” diagnosed him with complications from an earlier COVID infection and possible heart failure, the report says.
“No additional clinical investigations were taken,” the report says.
After the assessment, Mr. A went to another hospital seeking treatment for a dislocated shoulder. While there, the MAID provider tried to have him discharged. Doctors refused and readmitted Mr. A for psychiatric care.
The next day Mr. A was discharged at the MAID provider’s request. A psychiatrist raised concerns, but the MAID provider did not investigate further. Mr. A’s MAID death occurred at home.
Many committee members did not think the situation was urgent enough for MAID to be administered the day after the approval. Many also said Mr. A’s suffering could have been relieved through better psychiatric and geriatric care.
“I see MAID as a further failure of the government,” committee member Dr. Ramona Coelho, a family doctor in London, Ont., told Canadian Affairs. “They can’t fix their [health-care] system. They’re offering an easy way out, but it’s because they’re not fixing their system.”
Concerns about consent
The final case detailed in the report raised concerns about whether all patients in same-day MAID cases have consented to MAID.
Mr. C, a man in his 70s recently diagnosed with metastatic cancer, received MAID even though palliative care doctors believed he had lost the capacity to consent.
Five days after entering in-hospital palliative care, Mr. C. requested MAID. During the next two days, Mr. C lost his ability to communicate and experienced what the report calls “an altered state of consciousness.” Mr. C’s substitute decision maker agreed with his palliative doctors to have him moved to a hospice that day.
Before he could be moved to hospice, two MAID assessors approved him for MAID, even though all Mr. C could do was nod, blink or say “yes.” One of the assessments was virtual.
Some committee members were concerned about a possible lack of co-ordination between the palliative care and MAID teams that may have prevented Mr. C’s planned transfer to a hospice.
“All practitioners should consider existing and evolving end-of-life care plans and wishes in their approach to MAID care,” the committee wrote.
‘Adequate time’
The MAID Death Review Committee makes recommendations to the federal and provincial government, as well as medical organizations, about MAID.
Committee reports from last fall showed concerns that people with disabilities were opting for MAID due to inadequate housing and supports. Those reports included recommendations that Health Canada provide more guidance for determining MAID eligibility when patients’ suffering is caused by social conditions. They also recommended Ontario create a provincially co-ordinated MAID system that ensures people with complex needs have access to adequate care.
In the report released this April, the committee recommended that spousal burnout be included in eligibility criteria for in-patient palliative care in Ontario.
Some committee members also said an “in-depth review” should occur after every same-day or next-day MAID death.
“MAID practitioners should consider that adequate time is needed to ensure a requestor is informed of options to alleviate suffering, and that these options are appreciated, to provide informed consent,” the report says.
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