From east to west…striking the balance with internal flights
From the Atlantic provinces to the mainland and a packed few weeks, moving every 3 to 4 days from city city, east to west, meeting teams working and running MAiD programs, Assessors/providers (as MAiD/VAD practitioners are known in Canada) and those guiding national developments such as a curriculum, standardised models and research priorities.
Despite no further delays to baggage, the multiple internal flights meant a careful evaluation and re-configuration of my baggage and packing every few days. I had to be careful not to exceed my baggage weight limit, which was rather less than my original, departing international weight limit. No shopping or acquisition of books, theses or other written resources for me….maybe ….
My first stop was Ontario, the most populous province of over 15 million Canadians and home to the country’s political capital, Ottawa which was indeed my next destination. The wonderful team at The Ottawa Hospital (TOH) had already welcomed me heartily when we met at the conference in Halifax and they invited me to join them for dinner (remember, the oyster shooters?! 🫣)
I spent time with TOH program which is a predominantly hospital-based program run by a wonderful Quebecoise Advanced Practice Nurse and has a team of nursing and non-nursing coordinators. They serve similar functions of coordination as Australian care navigation/coordination services do, including gathering clinical information, identifying and referring to practitioners (known as assessors and providers in Canada), navigating location and facility challenges and barriers. They collaborate and rely on existing multidisciplinary teams and their allied heath staff to support patients and families around end of life preparation.
The Ottawa Hospital:
Rather more impressive from the outside than the basement, which reminded me of the RPH tunnel in Perth! 😆
The assessors/providers connected to this program see patients relatively independently, including on the day of provision (administration of substance), unless there’s identified reason to warrant otherwise from intake and triage conversations. The program’s medical lead generously gave me a full day shadowing him and answering my many questions about local and national issues, including federal reporting, Track 2 and waiver implications, the forthcoming expansion to include primary psychiatric illness in the MAiD eligibility (delayed to 2024). He is a wonderful, good-humoured and very pragmatic bloke who helped contextualise some of the issues raised at the recent CAMAP conference. And who’d have thought that I’d come all this way to get an Aussie gift from a patient’s family member, written in French!! She was delighted to discover I was an Aussie and was sure it was a fortuitous sign!
For those in the community whom TOH and other hospital-based programs are unable to support, they’re referred to the provincial MAiD coordinator who is also a NP and assessor/provider. This referral process serves as a bit of a provincial referral clearing house for self-referrals and when people are not already able to access local MAiD assessors or programs, where they exist.
En route south by train to Hamilton (who doesn’t love a good train trip?!) I stopped off in Toronto to visit MAiD House, a facility and service that many talk about trying to replicate in Western Australia.
There is, understandably, sensitivity around this facility and its location, which has had a couple of ‘homes’ since it first opened its doors to the community only 2 years ago, in the middle of the pandemic. I spent some time with the executive director hearing about its interesting origins and history. Most surprisingly was their original ‘pop-up’ location in part of a church! The current, more enduring facility provides a warm, welcoming and homely environment, as one would expect, with a room that felt a little like someone’s lounge room, along with adjacent rooms that serve as consulting rooms. The numbers of people using MAiD House are still quite low, recognising it’s still a fairly new option available in Ontario, and likely only suitable for those in the greater Toronto vicinity, but use of the facility has increased this past year.
I moved on to Hamilton, further south again, and met with two different ‘teams’ - first stop, to meet with the hospital-based team at Hamilton Health Sciences (HHS) led by the well-published Andrea Frolic and her coordination counterpart Marta Simpson-Tirone. Andrea is a bio-ethicist and Marta a registered psychotherapist and they were a lovely duo with whom to talk through the ethically-informed development of what Andrea calls ‘an ecology of care’ in establishing their MAiD program. https://link.springer.com/article/10.1007/s10730-022-09487-7
NB: there is an entire edition of the Healthcare Ethics Committee Forum journal devoted to the evolution and controversies in MAiD, published in December 2022:
HHS had strong medical support and involvement in the development of the program, but is essentially run by non-clinicians, who engage, support and maintain a referral network of MAiD assessors and providers. What they describe sounds to have become a culture of care that is both beautifully inclusive and supportive of people’s diverse perspectives on MAiD across their organisation.
The preponderance of ethicists in MAiD teams and spaces became apparent to me at the CAMAP conference and has been a particularly interesting revelation that probably shouldn’t have surprised me. It is of course, a field that presents considerable ethical debate, but I have never encountered so many with bio-ethics backgrounds involved in the running of clinical services. It is on my ‘hit-list’ on my return home, to go hunting for who the various ethicists might be in Western Australian health services, and what scope they have to contribute to VAD programs and discussions, such is my ignorance of any formal roles in our health system.
Unexpected heat in the Hamilton spring sunshine was both a blessing - time reflecting and writing outside with some furry friends - and a curse - I had packed NOTHING for warmer weather….so off to do some op-shop shopping I must go! Baggage limits?? Deal with them later…
The stroll through Hamilton streets certainly presented some contrasts to me - beautiful parks and gardens, abutting some grittier areas. And the ubiquitous cannabis stores that I will just never get used to seeing along every street. I knew as I strolled casually past what I soon came to see were naloxone kits hanging on a fence, that I’d strayed a little far. And yet I found some comfort in the visibility and availability of these resources, in what was very clearly an area that warranted them. It was both heartbreaking and reassuring in equal measure.
To my next meeting with the Hamilton ‘community team’, who are are essentially two wonderful family doctors (GPs) who are actively engaged in MAiD and CAMAP and serve as a regional contact point for any/all in the Hamilton area outside the hospital settings. They provide education, mentorship, public advocacy, as well as being key referral points for persons seeking MAiD in the community. While they collaborate with the Hamilton Health Service program, they do not have any direct support from a coordination service and seem to carry the weight of growing and supporting both patients and health professionals in the community in all things MAiD, including mentorship, education and advocacy, as well as providing MAiD. We met on the delightful deck of one of their homes just out of town, over antipasto and gin - a perfect facilitator of conversation!
Not for the first, or the last time, I would reflect on the relative freedom that is available for those beyond the constraints of public health employment. The opportunity that exists for private and independent practitioners to voice their opinions, challenge mis-information and to engage in the debate about contentious issues such as faith-based facility limitations, and the impact of individual clinicians’ conscientious objection on people seeking support and care when exploring this end of life option, is something that has been utilised well and with effect here in Canada. But this relative ‘freedom’ does not come without risk and sometimes cost.
Tip of the Day: expandable suitcases and carry-on do not aid in managing baggage weight limits!
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