The wonderful west…of Canada!
The decision to spend 4 weeks in Canada wasn’t my original plan in March of last year when preparing my Fellowship application, but evolved as I was finalising my itinerary earlier this year. And it has been, without doubt, one of the best decisions I’ve made in this Fellowship. Canada has NOT disappointed!
✈️ A chance encounter in the hotel bar the evening before the CAMAP conference in Halifax, led me to change my plans for the west coast of Canada and instead of flying from Calgary to Vancouver, I flew directly to Comox Valley on Vancouver Island. It’s a small but significant part of a region in Canada that has certainly been part of the moving-and-shaking in MAiD. Indeed, Vancouver Island is home to several of the founders of CAMAP which, as I’ve mentioned in previous blog posts, is now a pivotal organisation in guiding and shaping how MAiD is provided and how the workforce is prepared and supported as MAiD rapidly evolves in this country.
So into this pristine valley I flew (on some tiny toy plane, I might add!!) at the invitation of one of the CAMAP founders - a generous, hilarious, brutally honest and indomitable GP for whom I had felt an instant fondness when we first met by chance over a cocktail in Halifax. She and one of her GP colleagues - both expat Canadians - engaged early with MAiD with the announcement of Canada’s criminal code exemption and started preparing for its implementation in 2016 in their part of the island.
There’s a significant amount of community support and uptake of MAiD amongst the small population on an island that attracts a high proportion of retirees from many provinces (and beyond), seeking good weather and excellent quality of life, and with the means to find these things on Vancouver Island. Perhaps this is one of the more influencing factors to the uptake of MAiD here, which is higher than the national average.
The early public discussions about MAiD in the Comox Valley identified some challenges with the position of the local faith-based facility that also housed the region’s palliative care facility, and was not supportive of MAiD provision on-site. The strong community demand was bolstered by the public voices of these two GPs, who quickly became known as MAiD providers and spoke up at various public fora to correct misinformation and ensure a balanced discourse. Such was the community support for the right to access MAiD that when government funding for additional hospice beds, and a new 70-bed extended care facility in the area was announced, an advocacy group was formed to give voice to how this funding should be directed.
The CAMAP GP with whom I spent 2 days was an active part of the local discussion and advocacy for government funding to be used in a way that ensured community was able to access their legal right to MAiD in any new health facilities being built. The end result was a contract with a non-faith based provider, which would eventually take control of all the hospice beds for the region. It was of course far more of a journey than a couple of paragraphs can capture, but ultimately demonstrates the role of this type of discussion and local ownership about health service planning. It also had me reflect on the opportunities and the scope available to health care workers to engage in such public debate. Those of us working for government are limited in the extent we can engage, but an informed health professional voice seems pivotal, when added to the community discussion.
Our conversations were rich and varied and delightfully peppered throughout a couple of glorious days exploring the nearby area…with some breezy ferry crossings to nearby islands. I can certainly see why she brought her family to live here after deciding to leave the instability of South Africa where she hailed from.
Having soaked up everything I could in a few days in Comox, I got into the wrong side of a car, hit the wrong side of the road and headed south to the island’s ‘capital’ of Victoria to meet with more MAiD folks, including the famed Dr Stefanie Green - author of This is Assisted Dying and co-founder of CAMAP. Stefanie had been the touchpoint for me this past year in planning my Canadian itinerary, putting me in touch with various people across the provinces.
But first, a day’s road trip…with some interesting sights along the way! 🐐😳
Colloquially known as ‘Goats on the Roof’ cafe and market (for some cryptic reason 🤔), this quirky little place was a perfectly located break along the most picturesque of journeys…but with food options that seriously made my teeth hurt just looking at them on the menu! I just do not understand the fascination with donuts and toppings in North America, but I’m afraid I don’t share it.
Vancouver Island has had a very coordinated approach to MAiD, courtesy of the health authority, Island Health, based in Victoria. With strong, supportive executive leadership, the authority’s MAiD Medical Director is a warm empathic gent who hails from Scotland and is well regarded by all the MAiD assessors and providers I met on the island. He serves as the conduit between those working ‘on the ground’ (either hospital or community based) and the Authority and Health Canada, the latter of whom determines the documentation required for MAiD and collates national and provincial data and reports. He’s a strong advocate for issues affecting those delivering the care and I spent a lovely lunch with he and the Island Health MAiD Program Manager discussing how the island’s services have evolved. The high uptake of MAiD on the island, along with the profile of some of the very public practitioners, has brought some scrutiny that, while not unwelcome, definitely keeps everyone on their toes.
I had been offered lodging in Victoria in a ‘suite’ connected to the house of one of the MAiD providers connected to the hospital program. It seems ‘suites’ are quite the thing in Canada, whether for extended family or to rent to lodgers. On this occasion, it served the wonderful purpose of affording me some time chatting with the general physician (known as ‘internists’ in North America and ‘hospitalists’ when ….yep based in a hospital) and spending time with her and her lovely family who welcomed me for BBQ dinners in their garden on a couple of nights.
I also spent an afternoon at Dr Stefanie Green’s rooms chatting through some of the evolution of MAiD on the island, as well as the evolution of CAMAP into the behemoth is now is. Stefanie is and has been a major force behind MAiD in Canada and one of the primary drivers behind the formation and development of CAMAP. The respect with which she is regarded was evident across the country. She is clearly a formidable force and it was a wonderful to spend time with her.
My major regret was not bringing my own copy of her autobiographical book for a signature!
Many of us working in VAD in Australia who have read her book readily identified with many of her reflections and musings from our own first years in this work - the early shaping and moulding of how we engage and discuss assisted dying with people (both patients and health professional peers), increasingly feeling the need to build boundaries and limits in what we agree to in this very person-centred work, self-care strategies, reflecting on those heartwarming cases and those rather more hair-raising and intriguing cases, and all the things in between.
For those who have not yet read her very relatable book, it’s worth the read, especially if you work in assisted dying (NB: she assures me the Australian edition has a different cover).
Stefanie very graciously - or perhaps because she couldn’t work out how to pry me out of her office - invited me home to share dinner with her and her delightful French husband, whom I also felt was somewhat familiar to me from reading her book. Stefanie and I covered most of what remained to be discussed relating to MAiD and CAMAP on the walk to her house, and then we settled in for a very relaxed and convivial meal chatting about everything else! I tried my hardest not to have a star-struck fan-girl air about me…but I’m not really sure I succeeded.
Vancouver Island felt to me like it was approaching the sort of embedded integration of assisted dying into end of life care, that exists in The Netherlands and Belgium. I recognise the view from here is one rather skewed by the people with whom I’ve had an audience, but there was definitely something about my conversations at this side of the country that felt less ‘novel’ and emerging, even if not entirely embedded yet. There certainly remain some challenges ahead, as with the rest of Canada, as they prepare for March 2024 when MAiD will be expanded to include primary mental illness as the sole underlying medical condition, which is referred to within CAMAP as MD-SUMC. This was the focus of much of the CAMAP presentations and discussion, following the passage of Bill C-39 which delayed this expanded inclusion for an additional year of time to prepare workforce and processes. As remains the situation in the experienced European countries, the psychiatry workforce has been slower to engage, often in an already under-resourced context, and the impact of MD-SUMC will add another layer of complexity for the existing MAiD workforce.
My final stop in Canada was Vancouver where the MAiD Program Director, a wonderful RN, had corralled various team members on an hourly schedule to meet with me. The only program across the country that has developed a role of MAiD Clinical Educator! They cover about a third of greater Vancouver with 3 major hospitals and a few smaller sites and facilities, including one faith-based facility. The educator is a full time position and the nurse currently in that role assured me that he is kept more than busy organising, preparing and delivering education across clinical settings and sites. It’s a position that is coveted by other programs and I can certainly see how it could augment a program and support health care settings. The Program Director has a reputation across the country as being someone who has made all manner of things come to fruition; a very valuable asset in the progressive province of British Columbia.
Tip of the day: for those on the quest towards zero waste, consider a goat! 🐐
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