Interim Guidance on Physician-Assisted Death – Update: Document Approved

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    Stakeholder feedback

    View the feedback we received to our online survey View the comments posted to our online discussion page

    Our Process

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    The College’s Interim Guidance on Physician-Assisted Death received final approval from Council on January 26th, 2016.  The document was developed to ensure that Ontario physicians were aware of their professional and legal obligations with respect to physician-assisted death. This page has been developed to highlight the feedback received during the consultation period, and to outline some of the key revisions made to the Interim Guidance document in light of this feedback.

    Please note that the College’s Interim Guidance on Physician Assisted Death has been replaced by the current Medical Assistance in Dying policy. The policy is consistent with the Interim Guidance document, with amendments made to ensure alignment with the federal legislation.

    people

    Who we heard from

    • 2194 submissions were received in response to this consultation
    • The majoirty of feedback was received from physicians and members of the public
    • We also heard from a number of organizations such as the Ontario Medical Association; Ontario Hospital Association; Advocacy Centre for the Elderly; Canadian Medical Protective Association; Christian Medical and Dental Society; and the College of Nurses of Ontario
    View the feedback: Survey reportWritten Comments

    What we heard

    Other important considerations

    • Many respondents sought clarity on the eligibility criteria for physician-assisted death, particularly the types of medical conditions that would be considered ‘grievous and irremediable’
    • Some respondents expressed concern regarding the requirement that patients be competent at the time physician-assisted death is provided, noting the potential implications for those with mental illnesses.
    • The requirement that a physician, who objects to providing physician-assisted death for reasons of conscience or religion, provide the patient with an ‘effective referral’, garnered significant and divided feedback.
        • Stakeholders in favour of the ‘effective referral’ requirement opined that this approach reconciles physician and patient rights’. Many of those opposed to the ‘effective referral’ requirement felt that the referring physician would be morally culpable.
    • A number of respondents provided feedback on the ‘Sample Process Map’ section of the draft document
        • Respondents commented that the 15-day reflection period between the first and second request for physician-assisted death was arbitrary, and may not be appropriate in all circumstances.
        • Feedback was also received on the requirement that the second request for physician-assisted death be signed by two witnesses. This was seen by some to be overly burdensome in practice.
    • The Interim Guidance document was directly informed by the Supreme Court of Canada`s decision in Carter v. Canada.  It also incorporated direction from the Supreme Court of Canada and the Chief Justice of the Superior Court in Ontario regarding interim access to physician-assisted death, prior to Carter coming into effect.
    • The draft Interim Guidance document was developed in consideration of the work of Canadian medical regulators, the Federation of Medical Regulatory Authorities of Canada (FMRAC) and the Canadian Medical Association (CMA).  The frameworks in place in jurisdictions where physician-assisted death is legal were also examined.


    How we responded to your feedback

    Policy Decision

    Rationale

    • Content added to the document’s introduction to signal that from February 6 – June 6, 2016, physician-assisted death was accessible to those granted an exemption by a Superior Court Judge.
    • Reflects ruling by the Supreme Court of Canada to extend the 1-year suspension period set out in Carter by 4 months. This extension period provides the federal government with additional time to pass legislation on physician-assisted death.
    • A number of changes were made to the Sample Process Map to enhance clarity and to facilitate access to physician-assisted death for those deemed eligible. Those changes included:
    • Requiring that one independent witness countersign the patient’s second request for physician-assisted death.
    • This change was made in response to feedback that the two witness requirement contained in the draft may be challenging for some, and consequently compromise access to physician-assisted death for those who may be otherwise eligible.
    • Clarifying that where the attending physician is not satisfied that the patient meets the Carter criteria, the patient is entitled to request a second opinion.
    • Added in response to inquiries from consultation participants who were concerned that a request for a second opinion would not be permitted.
    • Adopting a more flexible ‘Reflection Period’ between the first and second request for physician-assisted death.
    • This change was made in response to stakeholder feedback that 15 days may not be suitable in all circumstances. In some instances a longer waiting period may be warranted and in others a shorter period may be appropriate.
    • Signalling that the attending physician is responsible for assessing the patient, unless they have made an effective referral to another willing provider.
    • This was added to clarify that conscientious objectors are not required to assess whether the patient meets the criteria for physician-assisted death prior to making an effective referral.

    Update

    • On June 16, 2016, the federal government passed legislation to govern the provision of Medical Assistance in Dying in Canada. In light of this development, and to ensure that the College continued to provide accurate guidance to physicians and the public, CPSO Council rescinded the Interim Guidance document and approved an updated policy titled Medical Assistance in Dying.  This policy aligns with the federal legislation.

    Medical Assistance and Dying Policy

    • The Medical Assistance in Dying Policy is substantively consistent with the Interim Guidance document, with amendments made to ensure alignment with the federal legislation. It is now a formal policy of the College of Physicians and Surgeons of Ontario.

    Read the Final Policy