Medical Assistance In Dying (MAiD) Practice Guideline 2021 PDF

Medical Assistance in Dying (MAiD) Approved: 2018 Revised: November 2021 CONTENTS Role of the College of Alberta Psychologists............................................3 Introduction....................................................................................................4 Legislation Ov...

Medical Assistance in Dying (MAiD) Approved: 2018 Revised: November 2021 CONTENTS Role of the College of Alberta Psychologists............................................3 Introduction....................................................................................................4 Legislation Overview...........................................................................................4 Psychologists and MAiD................................................................................5 Ethical Values and Considerations..............................................................6 Standards of Practice and MAiD.................................................................7 Informed Consent:................................................................................................7 Record Keeping and Documentation:..........................................................7 Appendix A: Recommended “Do’s and Do Not’s” for Psychologists Who Participate in MAiD.....................................................9 Appendix B: MAiD Capacity Assessment Checklist..................................11 Role of the College of Alberta Psychologists The role of the College of Alberta Psychologists (CAP) is to protect and maintain the confidence of the public by ensuring that psychologists engage in competent, skilled, and thoughtful practice through establishing and implementing entry to practice requirements, professional standards, and codes of ethics. This includes psychologists’ participation in a collaborative practice environment related to Medical Assistance in Dying (MAiD). As a regulatory body, the CAP does not engage in the philosophical/moral debate or adopt a position on MAiD. Furthermore, CAP does not provide legal or clinical prescriptive advice to practitioners. Psychologists are self-regulated and professional judgement is essential, given the highly contextual nature of service delivery. The Canadian Psychological Association’s Canadian Code of Ethics for Psychologists, along with the CAP’s Standards of Practice, are the minimum standards of professional behaviour and ethical conduct expected of all regulated members in Alberta. The role of this Practice Guideline is to provide further information for members in complex areas associated with MAiD. The guideline does not replace the importance of having the requisite education, knowledge, and specific training in the range of uses associated with MAiD. For further clarification, members are encouraged to consult with CAP’s Professional Guidance Department or the Practice Advisor Program through the Psychologists’ Association of Alberta (PAA), and to seek independent legal advice and/or contact Alberta Health Services’ MAiD Care Coordination Service. Practice Guideline - Medical Assistance in Dying 3 Medical Assistance in Dying: An Introduction In February 2015, in the Carter v. Canada ruling, the Supreme Court allowed for a person to request and receive, under specific circumstances, medical assistance in dying (MAiD). The federal government passed Bill C-14 on June 17, 2016, amending the Criminal Code to provide legal protection for those who aid physicians and nurse practitioners in providing this service (including psychologists). On March 17, 2021, the federal government passed Bill C-7, further amending the Criminal Code to allow persons whose natural death is not reasonably foreseeable to access the MAiD program under specific circumstances. Legislation Overview Section 241(2) of the Criminal Code provides that medical practitioners (defined as persons entitled to practice medicine in a province) and nurse practitioners can provide medical assistance in dying, provided the specified conditions in the Criminal Code are all met. Section 241(5.1) of the Criminal Code provides protection from prosecution to psychologists who provide information on the lawful provision of MAiD. Section 241(5.1) states: “For greater certainty, no social worker, psychologist, psychiatrist, therapist, medical practitioner, nurse practitioner or other healthcare professional commits an offence if they provide information to a person on the lawful provision of medical assistance in dying.” Because the federal provision extends only to information pertaining to the “lawful provision” of MAiD, it is recommended that psychologists ensure the information they provide is strictly accurate and objective, and that they seek further information and advice when in doubt. It is also strongly recommended that any client seeking information about MAiD who is not under the care of a medical practitioner or nurse practitioner providing MAiD be initially referred to the Alberta Health Services’ MAiD Coordination Care Services prior to engaging in MAiD-related discussions. This is to ensure it is clearly established and documented that the client meets the MAiDrelated criteria established by law. Medical and nurse practitioners have always been required to report formal requests for MAiD to the Minister of Health. Section 241.31(1.1) of the 2021 amendments extends this reporting requirement to persons responsible for preliminary assessments of MAID eligibility. Now, persons who assess MAiD eligibility on a preliminary basis, even without a formal MAiD request, are required to report that assessment to the Minister of Health. A person who knowingly fails to comply with this provision may be subject to an offence under section 241.31(4). The term “preliminary assessment” has not been defined in the Criminal Code, which leaves some uncertainty in which professions may be caught by this provision. However, on the Government of Canada’s website it refers to “other practitioners” being required to report “preliminary assessments” so that the Government can better track requests for MAiD. Out of an abundance of caution, psychologists should report to the Minister of Health when any patient requests information about MAiD. Practice Guideline - Medical Assistance in Dying 4 Psychologists and MAiD Psychologists may offer clinical support, engage in the professional activity of formal assessment, provide education and training, engage in research, and/or contribute to policy development related to MAiD. Additionally, they may be asked to participate on ethics committees, multidisciplinary teams, etc., related to emerging standards regarding MAiD. Further, section 241.2(5.1) of the Criminal Code now allows professional health care and personal care providers to act as independent witnesses to a MAID request, which is assumed to include psychologists. Under the legislation, psychologists are permitted to provide professional services within their scope of practice to assist a physician or nurse practitioner in support of MAiD. Nonetheless, psychologists who provide care or treatment to an individual exploring, seeking, or receiving MAiD must ensure they have complied with all relevant federal and provincial laws in all respects, along with adhering to the Code of Ethics and Standards of Practice associated with the College of Alberta Psychologists. Psychologists may engage in MAiD-related information-sharing with clients; however, psychologists are to ensure the client to whom they are providing MAiD-related treatment is eligible to receive MAiD. Psychologists are not to engage in MAiD-related treatment without written referral from the primary physician in the client record and the psychologist should ensure that the referral by the physician confirms the client is eligible for MAiD. It is important that psychologists are aware of the expanded MAiD eligibility to include persons whose natural death is not reasonably foreseeable. As per the Criminal Code of Canada 241(1) it remains a criminal offence to “counsel a person to die by suicide or abets a person in dying by suicide; or aids a person to die by suicide.” As such, psychologists ensure they do not direct, and are not perceived as directing, a client to consider medical assistance in dying. The new MAiD program allows persons whose natural death is not reasonably foreseeable to access MAiD under certain circumstances. A condition to accessing MAiD in this way is that the person be informed of all other means available to relieve their suffering, including counselling and mental health services. The person must also be offered consultations with professionals who provide these services, which will include psychologists. In March of 2023, mental illness will be a qualifying illness to access MAID. Given that the work of psychologists touches this issue, psychologists should monitor this legislative change closely over the next two years. Conscientious Objection: Psychologists, like other health professionals, are not obligated to participate in MAiD-related activities if it is contrary to their moral values and beliefs. This is consistent with s. 241.2(9) of the Criminal Code, which states, “For greater certainty, nothing in this section compels an individual to provide or assist in providing medical assistance in dying.” Psychologists wishing to exercise their right to conscientiously object are to notify their employer of their beliefs and/or make appropriate referrals via the Alberta Medical Assistance in Dying Care Coordination Service. Nonetheless, psychologists have a duty to ensure their values and beliefs do not interfere with the autonomy of clients by making alternative care arrangements. As well, they must not withhold information or impede access to MAiD. Practice Guideline - Medical Assistance in Dying 5 Ethical Values and Considerations The Canadian Code of Ethics for Psychologists delineates the principles, values, and behaviour required for ethical practice/decision-making while engaging in the profession of psychology. Four foundational principles are to be considered and balanced when making professional decisions as a psychologist, including those related to MAiD collaborative care. While all four are to be considered, they have been weighted in order to assist in complex decision-making where one or more principles may conflict. Principle I: Respect for Dignity of Persons Traditionally this principle is only surpassed when there is a “clear and imminent danger to the physical safety of any person.” Within the context of MAiD, the ethical standards of informed consent and freedom of consent are paramount in that psychologists recognize a competent individual’s inalienable rights of selfdetermination and personal liberty. Psychologists have an obligation to acknowledge and respect these rights. This obligation also takes into consideration the client’s degree of vulnerability and dependency. Principle II: Responsible Caring A fundamental tenet of health disciplines is that members should do no harm and services should benefit clients. Within the context of MAiD, client welfare remains a crucial consideration. Responsible caring leads psychologists to have clients consider not only their welfare but that of others when engaged in decision-making activities. Psychologists’ concern for others extends to their client’s family, community, and other treating health professionals. This principle also requires psychologists to be mindful of how their own values, attitudes, experiences, etc., may influence their professional activities. Competence and self-knowledge are essential to providing psychosocial interventions of this nature. Principle III: Integrity of Relationships Integrity, honesty, and openness are fundamental to professional psychological relationships and to the relationship the profession holds with the public. Psychologists are expected to be objective and act in the best interests of their client and others. Integrity in relationships includes not engaging in professional activities outside of one’s area of competence, honouring all commitments, and avoiding potential conflicts of interest by adhering to professional practice standards and the Code of Ethics. Principle IV: Responsibility to Society Psychologists have an extended responsibility to others and to their community. This includes the recognition that social values and societal expectations change. Psychologists are encouraged to constructively support such developments and to keep informed on social policies and related legislative developments. Practice Guideline - Medical Assistance in Dying 6 Standards of Practice and MAiD Psychologists are also obligated to ensure any MAiD-related activities align with CAP’s Standards of Practice. These include (but are not limited to) practicing within one’s area of competence and providing opinions only with substantial and direct contact for that specific purpose. The following two areas have been highlighted as of great consequence to the client, the public, and the psychologist with regard to MAiD-related psychological services. Informed Consent: MAiD-related informed consent processes must be made in a manner consistent with CAP’s collaborative practice expectations. It is preferable to obtain written, signed, and dated consent directly from the client after the psychologist providing the service outlines as much information as “a reasonable or prudent person” would want to know. This information, at a minimum, should include: the purpose and nature of the activity; mutual responsibilities; confidentiality protections and limitations; likely risks and benefits; alternatives; likely consequences of non-action; option to withdraw at any time without prejudice; over what time the consent applies; the possibility of a waiver of the final consent requirement; and, how to rescind consent, if desired. With the understanding that informed consent is an ongoing process, it may be appropriate to revisit and document the process throughout the course of services. Psychologists ought to be especially cautious in establishing freedom of consent, and must take all reasonable steps to ensure informed consent and MAiD decisions are not made under conditions of undue pressure, cognitive/mental or emotional distortion, states of coercion, and/or for financial benefit. Psychologists engage in appropriate and reasonable steps to problem-solve potential alternatives to MAiD while safeguarding the client’s autonomy. Psychologists traditionally accept and document oral consent in situations where signed consent forms may not be appropriate, including if the client is unable to sign and date their consent. Given the gravity of client records and MAiD, psychologists will want to carefully consider the value of written documentation and maintain records of the reasoned decision whereby signed consent documents are not obtained. Record Keeping and Documentation: Maintaining client records is a required professional activity described explicitly in CAP’s Standards of Practice. MAiD client records may also be reviewed in light of federal legislation. Specifically, the Criminal Code makes it a criminal offence to tamper with MAiD-related documents for the purpose of interfering with a person’s rights in regard to MAiD. Sections 241.4(1) to (4) state: Forgery 1) Everyone commits an offence who commits forgery in relation to a request for medical assistance in dying. Practice Guideline - Medical Assistance in Dying 7 Destruction of Documents Definition of Document 2) Everyone commits an offence who destroys a document that relates to a request for medical assistance in dying with intent to interfere with: 4) In subsection (2), document has the same meaning as in section 321 a) another person’s access to medical assistance in dying; b) the lawful assessment of a request for medical assistance in dying; or c) another person invoking an exemption under any of subsections 227(1) or (2), 241(2) to (5) or 245(2). Punishment 3) Everyone who commits an offence under subsection (1) or (2) is liable a) document means any paper, parchment or other material on which is recorded or marked; b) anything that is capable of being read or understood by a person, computer system or other device. It is now an offence under section 241.31(1.1) of the Criminal Code for persons responsible for preliminary assessments to knowingly fail to comply with reporting requirements outlined in the Regulations for the Monitoring of Medical Assistance in Dying. a) on conviction or indictment, to a term of imprisonment of not more than five years; or b) on summary conviction, to a term of imprisonment of not more than 18 months. Practice Guideline - Medical Assistance in Dying 8 Appendix A: Recommended “Do’s and Do Not’s” for Psychologists Who Participate in MAiD DO: Do ensure you understand current federal and provincial legislation governing MAiD. Do ensure compliance with federal and provincial legislation, including, but not limited to: » that the client to whom you are providing MAiD-related treatment is eligible to receive MAiD, » that you have made all reasonable efforts to ensure the medical practitioner or nurse practitioner who provides MAiD has complied with legislative safeguards and applicable practice standards. Do ensure that practice standards, guidelines’ and protocols established by CAP, the AHS MAiD Care Coordination Service, or the employer with respect to providing MAiD have been complied with. Do document, and maintain documentation of, the sources of information upon which you relied. Do ensure that all informed consent and release of information procedures are in compliance with existing ethical principles and standards of practice. Do ensure you have the requisite education, knowledge, and training in the range of issues associated with MAiD, and the roles in which psychologists may occupy, including, but not limited to: capacity assessments, cognitive, personality and emotional assessments, and evidence-based supportive therapies for those involved. Do discuss your role with the primary medical caregiver and encourage all participants to work collaboratively. Do consult with peers and other professional resources to ensure your practices are in keeping with common and accepted practice, given the evolving nature of MAiD. Do create written, legible, and professional records. Do maintain records in a secure location. Practice Guideline - Medical Assistance in Dying 9 DO NOT: Do not discuss client-specific MAiDrelated questions unless a physician has provided written documentation that the client meets the primary medical conditions. Do not provide MAiD-related services without a supporting written referral from the primary physician that is on the client record. Do not discuss MAiD-related questions outside of a collaborative care environment without a supporting written referral from the primary physician whom is on the client record. Do not discuss the medical or pharmacological aspects or any other aspect of the MAiD process that is outside of the practice of psychologists. Do not participate in the storage, dispensing, or administration of any prescription intended for MAiD. Do not discuss or provide information about accessing alternative forms of dying that do not conform to the legislative regime governing MAiD. Do not discuss or release client information without the informed, written, signed, and dated consent of the client. Do not engage in any professional activities that are not within the scope of practice of psychologists as defined by the Health Professions Act. Do not occupy more than one role (i.e., assessor/therapist) or provide services to more than one party (individual/family). Do not proceed with providing assistance with MAiD if you have any concerns that the client is not eligible to receive MAiD and/or that the medical practitioner or nurse practitioner providing MAiD has not complied with legislative and practice requirements. Instead, cease to provide services and seek further information or advice. Practice Guideline - Medical Assistance in Dying 10 Appendix B: MAiD Capacity Assessment Checklist When a medical assessor is unsure whether the client/patient has the capacity to give free and informed consent, a psychologist may be requested to provide an assessment during the MAiD process. The following is offered to support the psychologist in being intentional in their practice. As a self-regulated professional, the registered member is responsible for all actions taken and/or not taken. College of Alberta Psychologists Resources: I am aware of, understand, and abide by the Canadian Code of Ethics for Psychologists. I am aware of, understand, and abide by the College of Alberta Psychologists’ Standards of Practice. I am aware of, understand, and abide by legislation and court decisions affecting the provision of psychological services as outlined in the following document: Jurisprudence: Legislation Naming or Affecting Psychologists in Alberta. I understand and have followed the College of Alberta Psychologists’ Practice Guidelines: » Informed Consent for Services » Psychologists and Medications » Professional Regulation and Psychologists General Principles: I understand that I am a self-regulated professional and responsible for decisions made and actions taken while performing psychological services. I have the competency, through education, training, or experience, to perform a capacity assessment that conforms to current professional standards. I am aware of, understand, and abide by current MAiD legislation at the provincial and federal levels of government. I am in a professional relationship with the client for the purpose of providing psychological services. I have obtained informed consent from the client in a manner understood by the client, and have documented the discussion, while providing new information in a timely manner. I ensure the client understands their right to change their mind about a MAiD decision. I have included others, such as family members, spiritual leaders, and/or cultural leaders, as part of the client’s MAiD decision. I have clarified the limits of confidentiality to all parties, including family, prior to providing service. Practice Guideline - Medical Assistance in Dying 11 I have created and will maintain written and legible professional records in such a manner as to protect the security and confidentiality of personal identifying information. As a member of the collaborative care team, I adhere to privacy legislation governing my practice, communicate the limits to confidentiality, and advocate for the client’s duty of confidentiality. Process Principles: During the interview and general assessment process, I have considered the influences that may limit the client’s judgement and ability to understand, reason, and make decisions related to the MAiD request, including, but not limited to: » the presence of significant social pressures » the presence of significant cognitive barriers » the understanding and implications of the client’s medical situation Practice Guideline - Medical Assistance in Dying 12