Medical Assistance in Dying is not driven by socioeconomic vulnerability or poor access to palliative care

February 12, 2020

A new study of people who received medical assistance in dying (MAiD) in Ontario found that about three quarters were followed by palliative care at the time of their request for MAiD, and recipients were younger, wealthier, more likely to be married and substantially less likely to live in an institution than the general population at time of death. These findings call into question common concerns that MAiD requests are driven by lack of access to palliative care services, or by socioeconomic vulnerabilities.

The article is published in CMAJ (Canadian Medical Association Journal).

MAiD was legalized in Canada in June 2016 and as of October 2018, 6749 Canadians have received MAiD.

The federal government and the government of Quebec are currently in consultation around MAiD and the drafting of new eligibility criteria following a decision of the Quebec Superior Court that one provision of the previous laws violated the Canadian Charter of Rights and Freedoms.Dr. James Downar“There has been and will be much discussion about socioeconomic vulnerability and access to palliative care, and how these factors influence requests for MAiD,” said Dr. James Downar,  specialist in critical care and palliative care at The Ottawa Hospital and University of Ottawa

“There has been and will be much discussion about socioeconomic vulnerability and access to palliative care, and how these factors influence requests for MAiD,” says Dr. James Downar, lead author of the study and a specialist in critical care and palliative care at The Ottawa Hospital and University of Ottawa, Ottawa, Ontario. “Since this study represents the largest published study comparing MAiD recipients to all deaths overall, and is Canadian data, it could help inform this discussion and the upcoming legislation.”

Researchers analyzed clinical and socioeconomic data from 2241 people who died following MAiD, and compared this with data from all 186 814 Ontarians who died between June 2016 to October 2018, using databases kept by the Office of the Chief Coroner for Ontario and ICES. Among those who died following MAiD, the median age was 75 years and half were women; almost two-thirds of patients (64%) had cancer, and 12% of patients had neurodegenerative disease, 8.5% had cardiovascular disease and 7.5% had respiratory disease.

Patients who received MAiD reported both physical (99.5%) and psychological (96.4%) suffering.  Palliative care providers were involved at any point in 77% of patients and with 74.4% of patients at time of their request for MAiD.

“We found that everyone who received MAiD reported either physical or psychological suffering or both, even though palliative care was involved at the time of the request in about 3 quarters of cases. This indicates that for most patients, the MAiD requests could not have been due to poor access to palliative care,” write the authors. 

Almost half (48.5%) were married and the majority (85%) lived in a private home before receiving MAiD. They were younger than people who did not receive MAiD and more likely to live in a higher income neighbourhood. The authors state that these findings suggest that MAiD requests are unlikely to be driven by social or economic vulnerability.

Requests for MAiD can be emotionally difficult for patients and families and any delays can exacerbate distress. The study found that only 6.6% of families reported challenges with access to MAiD and these delays were not associated with socioeconomic status or other factors. The authors noted, however, that the MAiD dataset only included people who actually received MAiD, so this would not reflect the experience of the patients who requested it but never received it.

“The data presented here do not address the moral question of whether any amount of suffering can justify the hastening of death. However, the growing trend toward legalization and use of MAiD in many parts of the world should prompt the health care and research community to improve our understanding and treatment of the type of distress that leads to a MAiD request,” the authors conclude.

In a related editorial, Dr. Andreas Laupacis, CMAJ’s editor-in-chief, writes “the results should allay fears that people are choosing MAiD because they have little social support or have poor access to health care. Downar and colleagues found the opposite, and their findings suggest that more attention needs to be paid to ensure that those who are socially or economically vulnerable and eligible for MAiD are aware that MAiD is an option.”

He cautions that as we move into a new era in which the Canadian government is considering expanding eligibility to MAiD to minors, people with severe mental illness and to those who anticipate losing the capacity to request MAiD in future, Canada will need new safeguards.

“If access to MAiD is expanded, new safeguards, specifically tailored to each new indication for MAiD, need to be put in place. Then, we must once more proceed with caution, measure and carefully reassess,” concludes Dr. Laupacis.

The study was conducted by researchers from The Ottawa Hospital and the University of Ottawa, Ottawa, Ontario; Sunnybrook Research Institute, The Joint Centre for Bioethics, University of Toronto, Office of the Chief Coroner, Government of Ontario; Queen’s University, Kingston.

Funding: This study had no specific funding. Research at The Ottawa Hospital is possible because of generous donations to The Ottawa Hospital Foundation.

Full reference: Early experience with medical assistant in dying in Ontario, Canada: a cohort study. James Downar, Robert Fowler, Roxanne Halko, Larkin Davenport Huyer, Andrea Hill Jennifer Gibson. CMAJ. February 12, 2020. doi: 10.1503/cmaj.200016

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About ICES: ICES is an independent, non-profit research institute that uses population-based health information to produce knowledge on a broad range of health care issues. Our unbiased evidence provides measures of health system performance, a clearer understanding of the shifting health care needs of Ontarians, and a stimulus for discussion of practical solutions to optimize scarce resources. ICES knowledge is highly regarded in Canada and abroad, and is widely used by government, hospitals, planners, and practitioners to make decisions about care delivery and to develop policy. In October 2018, the institute formerly known as the Institute for Clinical Evaluative Sciences formally adopted the initialism ICES as its official name. For the latest ICES news, follow us on Twitter: @ICESOntario

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