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Medical assistance in dyingWhat to do? What to say?Andrea Feldstain, PhD; Barry D. Bultz, PhD, Lara Cooke, MD, MSc, FRCPC; Eric Wasylenko, MD, CCFP, BSc, MHSc; and Jackson S.Y. Wu, MD, MSc, FRCPC

Andrea Feldstain, PhD, is a provisionally registered psychologist in the Department of Psychosocial Oncology, Tom baker Cancer Centre, Calgary

Barry D. Bultz, PhD, is Director of the Department of Psychosocial and rehabilitation Oncology, Tom baker Cancer Centre, and Professor and Head, Division of Psychosocial Oncology, Daniel Family Leadership Chair in Psychosocial Oncology, Cumming School of medicine, University of Calgary

Lara Cooke, MD, MSc (Med Ed), FRCPC (Neurology), is Associate Dean, Office of Continuing medical education and Professional Development, and Associate Professor of Neurology, Department of Clinical Neurosciences, Cumming School of medicine, University of Calgary

Eric Wasylenko, MD, CCFP (PC), BSc, MHSc (bioethics), is medical Advisor, medical Assistance in Dying Preparedness, Alberta Health Services

Jackson S.Y. Wu, MD, MSc (clin.epi.), FRCPC, is Clinical Associate Professor, Department of Oncology, Division of radiation Oncology, Tom baker Cancer Centre, University of Calgary

ABStRACt

Canadian health professionals have expressed a need to develop skills to respond to inquiries about and requests for medical assistance in dying following

the passage of new legislation in June 2016. In Alberta, the Department of Psychosocial and Rehabilitation Oncology at the Tom Baker Cancer Centre collaborated with local

experts to provide information, answer questions and practice conversations around medical assistance in dying. This article describes the knowledge needs expressed prior to the workshop, the workshop content, and post-workshop feedback from participants around training needs.

Keywords: medical assistance in dying, professional development, end-of-life care

“It looks like physician-assisted suicide is in limbo but your docs in Canada are moving forward with it anyhow.” This was a message received by author Andrea Feldstain from an American friend. She had read a timely — and potentially misleading — article in the New York Times that stated “[s]everal doctors have announced that they will proceed with offering assisted suicide to patients despite the absence of any formal system [...].”1

The article was published on June 6, 2016, the very day on which it ceased to be illegal for Canadian physicians (and medical teams) to support Canadian inquiries into or requests for medical assistance in dying. Since the Supreme Court of Canada’s February 2015 decision in Carter vs Canada,2 provincial and federal governments, health care

institutions, and professional regulatory bodies have been outlining policies to provide professional guidance. Howev-er, as of June 6, 2016, Federal Bill C-14 remained under review, and preparedness for medical assistance in dying varied greatly across the country. Existence of policies and guidelines, and their content, differed somewhat from one province to the next, leaving many healthcare teams in Canada unsure about how to proceed. Alberta was and still is at the forefront of detailed preparedness, ensuring that health systems can consistently provide patients access to medical assistance in dying, while remaining attentive to vulnerabilities that might influence patient requests, and addressing provider rights to choose to participate or not.

Despite detailed preparations, many providers expressed a need for guidance, especially around ways to sensitively engage with patients who request information about, or access to, assisted death. In response to the uncertainty, the Department of Psychosocial and Rehabilitation Oncology at the Tom Baker Cancer Centre in Calgary, AB, worked with local experts to create an informational workshop entitled “Medical assistance in dying (MAiD): What to do, what to say.” It was held on June 3, 2016, one business day before changes to the criminal code that would allow for medically assisted death. Attending the session were 19 clinicians, including 12 psychosocial and rehabilitation clinicians (4 clinical social workers, 4 psychologists, 1 psy-chiatrist, 2 physiotherapists, and 1 physiotherapy assistant), 1 clinical ethicist, 2 clinical nurse specialists, and 4 physicians (1 emergency medicine, 3 palliative care).

LEARNiNg NEEDSA pre-workshop survey was distributed to assess learning needs and goals. Ten participants completed the survey (3 psychologists, 2 physicians, 2 physiotherapists, 1 radiation oncologist, 1 nurse, 1 social worker), with number of years in practice ranging from <5 years (1/10) to >20 (4/10). Results revealed that the most common sources of informa-tion consulted prior to the session were media reports

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(10/10), the Carter vs Canada Supreme Court ruling (6/10), and updates from Alberta Health Services (6/10). Seven of these 10 participants had already had a MAiD conversation with a patient, and all anticipated having such conversations in the future. Participants were interested in learning about the following themes: knowledge and resources (7/10), communication skills (2/10), and role clarification (1/10). The top 3 resources named as possible sources of support for consultation about MAiD conversa-tions were physicians (7/10), palliative care professionals (4/10), and the patient’s family (3/10).

WoRkSHoP DESCRiPtioNThe workshop content was designed according to reported learning goals: knowledge and resources, communication skills and role clarification. Author Eric Wasylenko (pallia-tive care physician, ethicist and medical advisor for Alberta Health Services MAiD Preparedness) presented an over-view of MAiD. He included details of processes undertaken by the province and by Alberta Health Services to prepare patients, clinicians and organizations; answered participant questions; and provided information on resources for patients and clinicians. Author Jackson Wu (clinical associ-ate professor and radiation oncologist) described how he approached patient inquiries or requests for MAiD. He reviewed lessons from the literature that guide his clinical approach. Participants also heard from the widow of an Albertan who had received the AHS-approved procedure for assisted dying. Author Lara Cooke (neurologist and Associate Dean in the Office of Continuing Medical Educa-tion & Professional Development) discussed communica-tion skills and led participants in an exercise to practice MAiD conversations with an actor playing the patient role. A group debrief concluded the afternoon with a discussion about teamwork, roles and the workshop’s take-home mes-sages about how to move forward.

Post workshop, 8 clinicians (2 psychologists, 2 social workers, 1 neurologist, 1 physiotherapist, 1 clinical ethicist and 1 clinical nurse specialist) completed a feedback ques-tionnaire. Overall, response to the workshop was positive, and clinicians reported being able to use the workshop to inform and enhance their practice. Areas of anticipated change included how to proceed when information and referrals are requested, increased comfort in engaging in MAiD conversations, and a desire to seek further informa-tion or engage in self-reflection. The areas identified as most helpful were the practical elements: How to locate resources, how to handle conversations, hearing from the surviving spouse, and the role-playing exercise. Suggestions for improvements in the future included more theoretical/spiritual discussion, additional time for practice with the actor and/or in small groups, the inclusion of more diffi-cult or complex scenarios, and involvement of the local MAiD Care Coordination Team.

Contrary to the suggestion made in the New York Times article, Canadian physicians and teams have moved forward because they had to, even as education and practice in the art of these important conversations remains a work in progress.

The workshop described here aimed to help clinicians examine their own views, develop practices, and become more comfortable and confident about responding to inquiries and requests that will undoubtedly come forward. Feedback following the workshop suggests that preparation efforts such as clinically-focused workshops may help providers feel informed and assured. Care provider skill will help to create an environment in which patients feel supported as they explore their own end-of-life wishes.

References1. Austin I. “Political Impasse in Canada Puts Assisted Suicide in Legal Limbo”.

New York Times. 2016 June 06. Retrieved from http://www.nytimes.com/2016/06/07/world/americas/canada-euthanasia-law.html?rref=collection%2Ftimestopic%2FAssisted%20Suicide&action=click&contentCollection=timestopics&region=stream&module=stream_unit&version=latest&contentPlacement=2&pgtype=collection&_r=0. Accessed on June 20th, 2016

2. Carter v. Canada (Attorney General), SCC 5, [2015] 1 S.C.R. 331. Retrieved from the Department of Justice Canada website: https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/14637/index.do

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CoNgRAtuLAtioNSbefore the year is out, Oncology Exchange would like to congratulate our Clinical editor, Dr. barry bultz on being named the first chairholder of the Daniel Family Leadership Chair in Psychosocial Oncology. Professor and Head, Division of Psychosocial Oncology in the Cumming School of medicine at the University of Calgary, and Director of the Department of Psychosocial Oncology at the Tom baker Cancer Centre (TbCC), Dr. bultz has established a global reputation in the area of psychosocial oncology with his seminal research in “Distress as the Sixth Vital Sign” and his leadership in achieving International Union for Cancer Control (UICC) recognition of this important area. His research carried on both at TbCC and internationally, has demonstrated that 35-45 per cent of cancer patients experience high levels of distress; these findings have led to innovations in clinical care. The funding from this Chair will be instrumental in supporting ongoing research in this field with the clear vision of alleviating the distress faced by cancer patients and their families.