Concern about quality of palliative care
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* Ramona Coelho

In their article in *CMAJ*, Downar and colleagues draw conclusions that could have a far-reaching impact on the public’s perception of medical assistance in dying (MAiD), based on potentially misleading data.1 According to an article in the *Globe and Mail*, “The authors of the new Ontario research say its findings — which are based on reviews of every assisted-dying case in the province over 2 years — counter fears that the procedure would become a final refuge for patients too poor and vulnerable to access high-quality health services, including palliative care. Instead, the opposite has proved true: It is the affluent, not the marginalized, who most often avail themselves of the assisted-dying law that Canada enacted nearly four years ago.”2

The data for this study were based on self-reporting of the MAiD provider, and not by the patient. Evidence by self-reporting is often biased toward compliance with regulations. Case in point: a review of anonymous questionnaires from Belgium reveals that self-reporting led to only 1 in 2 cases being actually reported to authorities as euthanasia. Those not formally reported were correlated with decreased adherence to guidelines and lacking in palliative care involvement.3

Given we are on the brink of MAiD expansion in Canada without a foreseeable death clause, a study prematurely declaring no concerns for the vulnerable is alarming and reckless.

It is also important to consider whether being affluent precludes vulnerability. Is financial abuse of older adults a nonissue in Canada?4 Could poor clinical acumen in helping patients adjust to loss of power or function and high rates of depression still be hidden in these figures?

## Footnotes

*   **Competing interests:** None declared.

## References

1.  Downar J, Fowler RA, Halko R, et al. Early experience with medical assistance in dying in Ontario, Canada: a cohort study. CMAJ 2020; 192: E173–E181
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6NDoiY21haiI7czo1OiJyZXNpZCI7czoxMDoiMTkyLzgvRTE3MyI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xOTIvMjAvRTU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

2.  Grant K. Wealthier patients more likely to use medical assistance in dying, data show. Globe and Mail [Toronto]. Available: [www.theglobeandmail.com/canada/article-wealthier-patients-more-likely-to-use-medical-assistance-in-dying/](http://www.theglobeandmail.com/canada/article-wealthier-patients-more-likely-to-use-medical-assistance-in-dying/) (accessed 2020 Feb. 11).
    
    

3.  Smets T, Bilsen J, Cohen J, et al. Reporting of euthanasia in medical practice in Flanders, Belgium: cross sectional analysis of reported and unreported cases. BMJ 2010;341:c5174.
    
    [Abstract/FREE Full Text](http://www.cmaj.ca/lookup/ijlink/YTozOntzOjQ6InBhdGgiO3M6MTQ6Ii9sb29rdXAvaWpsaW5rIjtzOjU6InF1ZXJ5IjthOjQ6e3M6ODoibGlua1R5cGUiO3M6NDoiQUJTVCI7czoxMToiam91cm5hbENvZGUiO3M6MzoiYm1qIjtzOjU6InJlc2lkIjtzOjE3OiIzNDEvb2N0MDVfMi9jNTE3NCI7czo0OiJhdG9tIjtzOjIyOiIvY21hai8xOTIvMjAvRTU1Ni5hdG9tIjt9czo4OiJmcmFnbWVudCI7czowOiIiO30=) 

4.  Elder abuse: it’s time to face the reality. Ottawa: Employment and Social Development Canada; 2009, modified 2016 Oct. 24. Available: [www.canada.ca/en/employment-social-development/campaigns/elder-abuse/reality.html#a](http://www.canada.ca/en/employment-social-development/campaigns/elder-abuse/reality.html#a) (accessed 2020 Feb. 14).