Halifax hospitality to fill my head!
Last week I learned how many Canadians never make it to the eastern reaches of their country, when a group of Canada‘s Medical Assistance on Dying (MAiD) workforce, gathered for the first national face-to-face meeting of CAMAP (Canadian Association of Assessors and Providers) since 2019, before the COVID pandemic. Despite conferences not being the primary purpose or intended focus of a Churchill Fellowship, my planning and travels were essentially timed to wrap around this meeting, given the opportunity to connect with so many working in this space in one place. It was indeed the right decision - welcoming, rich with knowledge and expertise and a fabulous launchpad for the remainder of my Canadian stops. And such an eye-opener, in so very many ways!
I arrived in Halifax, Nova Scotia from Amsterdam with a few days to get accustomed to the new time zone, acclimatise (or acclimate, for those North Americans following this blog 😉) and ostensibly to have a good look around. Sadly, my luggage chose to have an extended stay in Toronto, so didn’t arrive until the middle of the following day, leaving me with limited layers to get out amongst things in what proved to be a bitterly cold few days.
Limited by weather, but eager to get a feel for the place, my trusty researcher directed me to the Halifax Central Library, which is also home to a cool little cafe, called Ampersand that boasts a great view, wifi and cheap, hearty food. It was a great place to get some notes done, hear and see some of the real people of this port city, which rather reminded me of my home town, Fremantle.…only MUCH colder! Strolling through the streets of Halifax also exposed me to real life in this unforgiving climate, where I have genuinely no idea how the homeless survive in their tents. I was here in spring, not in the depths of winter. I can’t imagine what becomes of people when it is truly cold, considering the chilly temperatures of spring had me cower indoors. It is so hard to swallow homelessness in wealthy countries like Canada and Australia, although I do not pretend to suggest it is a simple issue either in causation or solution.
This reflection provided me with some useful context in the coming days of the conference, where debates and discussion about the social determinants of health, and whether/when these contribute to people making requests for assisted dying under Canada’s more liberal and inclusive access criteria (Canada allows scope for people to access MAiD in certain circumstances without a terminal illness). It’s an uncomfortable notion, and one that again has me reassured about Australia’s conservative and restrictive entree into assisted dying availability.
But first, to meet some of my Canadians colleagues and peers at some pre-conference activities and meetings. I organised to meet with two wonderful humans, both MAiD practitioners based in Nova Scotia and playing host to the CAMAP conference. Erica Maynard is a Nurse Practitioner and Dr Gord Gubbitz a neurologist and both are MAiD practitioners and active CAMAP members who had agreed to meet with me in the lobby bar at the conference hotel.
What was meant to be a chance to hear from them about MAiD in Nova Scotia and what are known as the Atlantic Provences, turned quickly into a wonderful social gathering as incoming conference registrants trickled into the bar and joined us. Our planned discussions were derailed, but instead augmented by a rich group representing several Canadian provinces, including Ontario, British Columbia, Manitoba and Newfoundland.…by which stage the drinks and stories were flowing and the cameras well and truly away!
Many of the early arrivals were some of the CAMAP pioneers, arriving for pre-conference meetings, including a train-the-trainer session to test the new/draft MAiD curriculum that has been developed by a CAMAP working group, supported by a $3.1M Health Canada grant. They claim to have developed the world’s first MAiD curriculum, and I am again aghast at how little structure, direction and support the early MAiD workforce had in Canada. They were essentially told, “now it’s legal, go forth and work out how to make it happen’!
It has been an interesting and dramatic learning curve, hearing about the evolution of MAiD in this country, including its relatively rapid expansion from inception in 2016, to include what they know of as ‘Track 2’ criteria in 2021, under which a person can still qualify for MAiD without a ‘reasonably foreseeable natural death’ (this being the legal requirement for eligibility under the initial tranche of their legislation). It always baffled me, when reading about their legislation and in the CAMAP member forums that I’ve followed for a couple of years, how on earth ’reasonably foreseeable’ was determined and interpreted. And as I am coming to understand, this legal term is inconsistently understood and applied across MAiD assessors, with a spectrum from very conservative (3 months‘ prognosis) to rather more liberal (up to 2 or more years).
The experience we’re developing in Australia with people who do not fall within our more conservative and definitive criteria (which are still, themselves open to some degree of interpretation) does sometimes exclude people who are very clearly suffering, absolutely have a life-limiting illness and whose deteriorating quality of life and functional decline is both distressing and difficult for loved ones to bear witness to. So from afar, the concept of Canada’s Track 2 inclusions seemed to have merit. In theory, I think many Canadians agree. However, in practice, these requests and assessments are much more fraught than is immediately apparent. The criteria can be challenging to apply, the requests driven by many contexts and factors and are time-consuming to assess and the workload of Track 2 MAiD assessments is being born by a relatively small pool of people who are open to accepting these referrals.
Then there is the matter of Canada’s ‘waiver of final consent’, which is a legal mechanism by which someone - who must be meet Track 1 eligibility of having a reasonably foreseeable natural death, or RFND - who is either concerned about or at risk of losing capacity, can seek to make an explicit written agreement with their MAiD Provider (our version of Administering Practitioner) to proceed with a MAiD ‘provision’ (administration of the substance) on an agreed date, if the person has lost capacity. While this will sound quite shocking to some, those of us who have supported and borne witness to someone desperate to access VAD but who loses capacity before it is available, can see how this type of arrangement would also have merit, in very specific and carefully considered circumstances. And once again, the reality of its application is not without challenge here in Canada, with a wide variability in the willingness or providers to engage in and use such waivers. They do certainly add complexity to managing individual case scenarios and overall workload.
All of this gave me much to reflect upon, and once again I found myself quietly grateful that we have started small, slowly and moderately in Australia, allowing us time to learn and refine our processes and acquire experience, in more restrictive but less contentious clinical circumstances. I came to Canada assuming I’d be envious of their inclusive scope, their expertise and evolution with such national engagement and consistency. The reality on the ground is very different, and indeed very variable between provinces despite Canadian legislation being federal. Provincial interpretations, regulation, reporting and processes differ considerably, and in this way, is not dissimilar to the Australian VAD landscape.
Reflections on what I heard and learned in the conference and pre-conference workshops are still percolating in my mind, taking shape more and more from the reflective conversations I continue to have as I meet individually with teams across the country who attended the conference. But suffice to say, when I was invited out to a social gathering after the closing of the conference, with a team I would soon be visiting in their home province, who start their night with oyster shooters and quickly start levelling jokes and mockery at the alien in the group, I knew I had found ‘my people’!
Tip of the day: use of a luggage tracker may provide some reassurance about the location of one’s luggage, but it does not provide clean clothing!
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