MAID and Palliative Care: Lessons Learned and Future Directions
Written by: Neelakshi Sharma, MSc'25 (Candidate)
On November 2, 2023, the Department of Medicine and Oncology at Queen’s had the honour of having Dr. James Downar present an informative lecture on Medical Assistance in Dying (MAID) and Palliative Care (PC). Dr. Downar’s presentation revealed a complex landscape of demographic studies of MAID recipients in Canada, the current limitations and practical challenges in treating those who are suffering, and new therapies that address the distress that drives MAID. Once the presentation concluded, Dr. Downar engaged in a thought-provoking conversation with the TMED students.
MAID remains a deeply controversial topic, sparking passionate debates and divisions in society due to its ethical, moral and legal implications. In 2016, the perception of MAID evolved during the legal case of Carter vs. Canada AG which resulted in the legalization of MAID. At this time, MAID was legal for competent adults who could clearly consent to the termination of life, had a grievous and irremediable medical condition (including illness, disease or disability) and those enduring suffering that is intolerable to the individual in his or her condition. As of 2021, there are two assessment pathways. The first pathway is when death is reasonably foreseeable, which doesn’t require a reflection period and there is an optional waiver of final consent. The second pathway, known as “Track 2” requires a 90-day reflection and a second assessor that must have expertise in the condition causing suffering.
The legalization of MAID posed many questions within society regarding factors that drive MAID and the recipients of MAID. Dr. Downar highlighted that 52% of those who receive MAID in Canada are male and have a mean age of 76 (1). As well, the large majority are cancer patients (66%), those with ALS (Motor Neuron Disease, ~5%), cardiovascular disease (19%), respiratory disease (12%) and those who have lost the ability to engage in meaningful activities (86%) or activities of daily living (83%) (1). In a cohort study, they also found that poor people were much less likely to get MAID than rich people, and this trend was found in every demographic and illness subgroup (2,3).
In his presentation, Dr. Downar emphasized that a limitation of understanding PC, is that there is no way to measure the access to PC services, as it can be very subjective. For example, a patient can claim that care was received but if they didn’t receive care, it cannot be proven that they did or did not have access to it. However, what can be studied is looking at different populations that are known to have high quality or low-quality PC and early or late PC and this can help determine which factors truly drive MAID. Key findings of these studies have determined that factors such as PC access/quality, support needs/ ableism, poverty and loneliness/institutionalization are not driving MAID to any substantial degree.
So, what is driving MAID? According to a survey completed in 2020, some of the major factors driving MAID are loss of ability to engage in meaningful life activities (82.1%) and loss of ability to perform activities of daily living (78.1%) (Fig. 1) (4). An important distinction to make when looking at patient distress is looking at the cause. It is often not because they don’t have access to services, it’s that they require services, leading to feelings of burden (4).
As we approached the end of Dr. Downar’s presentation, he brought attention to patient cases in which MAID and PC have been misrepresented in the press due to its subjectivity. He also brought forth the idea of new therapeutics such as Repetitive Transcranial Magnetic Stimulation (rTMS) to treat depression and anxiety and psychedelic medications that might lead to the reduction in suffering, the driving force of MAID (5,6,7).
During our post-MGR discussion, Dr. Downar shared his knowledge and expertise in the field of PC and MAID and provided us with valuable advice as emerging scientist. It is evident that there are many different cultures that hold different beliefs toward MAID, however it is important to recognize that culture is always evolving, as is health care and advancements are made accordingly. If there was one life message, we took home from Dr. Downar, it would be that we as TMED students should strive to find purpose, in order to create a fulfilling lives for ourselves. All in all, the goal of PC is to focus on reducing the suffering of patients and improve patient quality of life, and it is imperative to understand that access to PC is not the only gap we have to close.
(750 words, excluding references, figure caption, and title).
- Gouvernement du Canada. (2023, October 26). Government of Canada. Canada.ca. https://www.canada.ca/en/health-canada/services/publications/health-sys…
- Downar, J., Fowler, R. A., Halko, R., Huyer, L. D., Hill, A. D., & Gibson, J. L. (2020). Early experience with medical assistance in dying in Ontario, Canada: a cohort study. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne, 192(8), E173–E181. https://doi.org/10.1503/cmaj.200016
- Redelmeier, D. A., Ng, K., Thiruchelvam, D., & Shafir, E. (2021). Association of socioeconomic status with medical assistance in dying: a case-control analysis. BMJ open, 11(5), e043547. https://doi.org/10.1136/bmjopen-2020-043547
- Canada, H. (2023, June 30). Government of Canada. Canada.ca. https://www.canada.ca/en/health-canada/services/publications/health-sys…
- Byock I. (2018). Taking Psychedelics Seriously. Journal of palliative medicine, 21(4), 417–421. https://doi.org/10.1089/jpm.2017.0684
- Griffiths, R. R., Johnson, M. W., Carducci, M. A., Umbricht, A., Richards, W. A., Richards, B. D., Cosimano, M. P., & Klinedinst, M. A. (2016). Psilocybin produces substantial and sustained decreases in depression and anxiety in patients with life-threatening cancer: A randomized double-blind trial. Journal of psychopharmacology (Oxford, England), 30(12), 1181–1197. https://doi.org/10.1177/0269881116675513
- Ross, S., Bossis, A., Guss, J., Agin-Liebes, G., Malone, T., Cohen, B., Mennenga, S. E., Belser, A., Kalliontzi, K., Babb, J., Su, Z., Corby, P., & Schmidt, B. L. (2016). Rapid and sustained symptom reduction following psilocybin treatment for anxiety and depression in patients with life-threatening cancer: a randomized controlled trial. Journal of psychopharmacology (Oxford, England), 30(12), 1165–1180. https://doi.org/10.1177/0269881116675512