September 29, 2016
Posted by Nadine Abdullah, MD, MEd, FRCPC
Posted by Nadine Abdullah, MD, MEd, FRCPC
The last phrase in Dr. Richardson’s original description of this series, “complex clinical environments”, prompted a timely topic for our inaugural lecture this year: Medical Assistance in Dying (MAID). Our learners asked how to deal with a request from a patient for MAID. How do we approach this in our own practice, and how do we teach about it in medical education?
Our goal was to create a safe space, recognizing and
respecting we each hold our own thoughts on MAID that we bring to the
discussion. Given the reality of the current legislation enacted June 17, 2016
rendering MAID legal in Canada, provided certain conditions are met, the focus of
our discussion was to move beyond moral and ethical debate, to engage and
prepare for the challenges in conversations we will have in our duty to our
patients. How do we do this?
Dr. Rodin led us briefly through an understanding of
Canadian MAID legislation and the UHN protocol for context. He used a case
based approach drawing on patients from his practice to highlight the types of
conversations that we should be prepared to have. He noted the analogy to patients requesting
futile treatment, where similar motivations are at the root, being a desire for
control and a sense of agency over the process of illness and death. Immediate
attention should be made to ensuring we address present symptoms and consider
alternatives to MAID, including pain control, discussing psychosocial aspects
of despair, and ensuring access to comprehensive palliative/supportive care. If
a desire remains, we need to ensure competence, lack of coercion, and
persistence of a sustained value system.
Early experience with MAID in Canada has shown that a
significant number of requests do not proceed after thoughtful conversations between
patients and their physicians about their motivations, and supporting their complex
needs. Dr. Rodin left us with a framework for a therapeutic approach to
speaking with patients. We need not fear our patients asking for assistance
dying, but embrace the conversations we can lead that remind us of our role in
humanistic medicine. As Flegel and Patrick remind us, if we become more comfortable discussing death with our
patients as part of our ordinary medical practice, conversations with patients
about MAID will become less frightening CMAJ, 18(10).
As a medical educator, I experienced this talk as an informal interactive session where students, residents and attending physicians were engaged, eagerly asking difficult questions. In the discussion prompted by those questions, I saw a contextualization of our CanMEDS Roles. To have these conversations, we need a solid foundation as a Medical Expert, while simultaneously enacting our intrinsic roles of Communicator, Collaborator, Health advocate, Leader, and Professional. But did the students and residents see this? Do we need to explicitly label the CanMEDS Roles in this teaching format in order for learners to see and incorporate them? Would that enhance and reinforce the learning, or interfere with the organic nature of this format? Did the involvement of attendings in the audience impact the outcome in a shared learning environment? We are interested in your thoughts, as we look to answer these questions over the year.
As a medical educator, I experienced this talk as an informal interactive session where students, residents and attending physicians were engaged, eagerly asking difficult questions. In the discussion prompted by those questions, I saw a contextualization of our CanMEDS Roles. To have these conversations, we need a solid foundation as a Medical Expert, while simultaneously enacting our intrinsic roles of Communicator, Collaborator, Health advocate, Leader, and Professional. But did the students and residents see this? Do we need to explicitly label the CanMEDS Roles in this teaching format in order for learners to see and incorporate them? Would that enhance and reinforce the learning, or interfere with the organic nature of this format? Did the involvement of attendings in the audience impact the outcome in a shared learning environment? We are interested in your thoughts, as we look to answer these questions over the year.
Bio - Gary Rodin MD
Gary Rodin is the University of Toronto/University
Health Network Chair in Psychosocial Oncology and Palliative Care and Head of
the Department of Supportive Care at Princess Margaret Cancer Centre in
Toronto, Canada. Dr. Rodin is also the Director of the Global Institute of
Psychosocial, Palliative and End-of-Life Care (GIPPEC) and a Professor of
Psychiatry at the University of Toronto. He leads a clinical and research
program on the psychosocial dimensions of advanced and terminal disease and on
the development and evaluation of novel interventions to improve the quality of
life and the quality of dying and death in this population. He has
published widely in these areas and is recognized internationally for his
efforts to improve the rigor of research and the effectiveness and availability
of psychosocial and palliative interventions. He is a key leader in the
development of MAID guidelines for UHN.Resources:
Canadian physicians are encouraged to consult with their provincial regulatory college and Canadian Medical Protective Agency (CMPA) in cases of discomfort addressing MAID, maintaining the right of conscientious objection, and if proceeding with MAID referral.
CMPA policy 2016
CanMEDS Framework
Flegel K and Patrick K. Discussing death with the living. Canadian Medical Association Journal 188(10) · May 2016
CanMEDS Framework
Flegel K and Patrick K. Discussing death with the living. Canadian Medical Association Journal 188(10) · May 2016
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