The letters from Drs. Violette and Bouchard,1 Ferrier2 and Coelho3 all seek further clarification about how palliative care involvement was defined. We direct readers to Appendix 2 of our article (available at available at www.cmaj.ca/lookup/suppl/doi:10.1503/cmaj.200016/-/DC1)4 for details about what was available in the medical assistance in dying (MAiD) database, and how we obtained this information.
There were 2 separate data fields relevant to palliative care: the specialty or subspecialty of the MAiD assessors and providers, and the involvement of a palliative care provider at the time of the MAiD request. For both questions, the assessment was made by a nurse investigator working for the Office of the Chief Coroner of Ontario. We determined the specialty or subspecialty of the MAiD assessors and providers with reference to the registry of the College of Physicians and Surgeons of Ontario and the College of Nurses of Ontario; however, some assessors and providers were designated as palliative care providers (even in the absence of a professional certification or designation) when we knew they were providing palliative care within a palliative care unit or palliative care team. The decision that a palliative care practitioner was involved was based on a thorough review of the notes and assessments and a telephone conversation with the MAiD provider. This assessment was not based on any billing information, and it was not based solely on the word of the MAiD provider.
In response to comments about credentials, we do not feel that it would be appropriate to judge the quality of palliative care on the basis of the credentials of the provider, especially in Canada. There was no accredited palliative care training in Canada before 1999, and the first subspecialty training programs were accredited only in 2016. Many of Canada’s foremost palliative care providers have been providing exceptional palliative care and palliative care instruction without the benefit of formal palliative care credentials.
We were not able to compare the prevalence of palliative care involvement in the MAiD cohort to any similar measure in the Ontario decedent cohort, as this level of detailed review is not available in the latter. However, as explained in the discussion, others have examined the prevalence of palliative care involvement among all Ontarians,5 and this number appears to be less than 50%, even when using the most broad definition of palliative care.
We acknowledge the comments of Drs. Gallagher and Passmore6 about the possible interpretations of the data we presented. To be clear, we are not denying that there are problems with access to palliative care in Canada; nor are we denying the existence of socioeconomic vulnerability. These are clearly issues, but according to our findings, they are very unlikely to be driving the provision of MAiD in Ontario. Indeed, access is hard to measure, but given that 75% of patients were being followed by a palliative care provider at the time of the request, it is hard to argue that poor access was a driving factor in MAiD provision. We will not dispute the personal experience of some providers, but the data collected by the coroner’s office suggest that these reports may not reflect the broader experience of a population.
Medical assistance in dying remains a controversial subject in the medical community, and the findings of our study do not resolve this controversy. But for those who are keen to address the underlying drivers of MAiD, our study offers some insight into what those might be.
Footnotes
Competing interests: James Downar is currently employed by Bruyère Continuing Care, a Catholic faith–based health care facility; he is a former unpaid member of the Clinicians Advisory Council of Dying with Dignity Canada, a group that advocated for legalization of medical assistance in dying (MAiD) in Canada; and he previously received consultation fees for curriculum development for a MAiD course offered by Joule, Inc. The work presented here does not represent the views of Bruyère Continuing Care, Dying with Dignity Canada, or Joule, Inc. Jennifer Gibson was co-chair of the Provincial-Territorial Expert Advisory Group on Physician-Assisted Dying (2015), which was commissioned by provincial and territorial governments to develop recommendations for the implementation of MAiD in Canada; she was also chair of the Advance Requests Working Group of the Council of Canadian Academies Expert Panel on Medical Assistance in Dying.