Demand spurs MAID provider shortage
Canada could soon end up with not enough doctors willing to participate in the country's assisted death regime, a new report warns.
The country faces a “looming crisis” in access to medically assisted death due to a dramatic rise in demand that threatens to outstrip the supply of “willing and available providers,” the authors wrote.
Some doctors, burned out from the stresses of the pandemic, are dropping the “add-on” work of MAID, other early adopters are retiring or moving on to other areas, and more doctors may opt to step away from MAID over the increased legal risks and “moral hazards” of ever-widening eligibility, they said.
Many MAID providers are already curtailing their practices by limiting MAID to those for whom the law was originally intended, the terminally ill.
The number of MAID deaths have grown from just over 1,000 in 2016, when assisted dying in Canada was formally legalized, to 31,644 in total by the end of 2021. More than 10,000 people died by MAID in 2021 alone.
Writing in HEC Forum, Dr. Andrea Frolic, director of the Office of Ethics and the medical assistance in dying program at Hamilton Health Sciences, and co-author Allyson Oliphant said the rapid uptake of MAID can be seen as a “triumph of patient advocacy.”
“However, the incredible `success' of the introduction of MAID in Canada is also putting access at risk,” they wrote. “It is not the law alone that facilitates access to MAID — rather it is individual clinicians who create the option for MAID by choosing to participate.”
There were 1,577 doctors and nurse practitioners providing MAID in Canada in 2021, up 17 per cent from 1,345 in 2020, according to the federal government's most recent annual report on MAID.
However, the number of people granted assisted death increased by nearly double that amount (32 per cent).
“This represents (an) estimated 230 missing MAID providers across the country in 2021 alone, if the rate of new recruitment of new MAID providers were to keep pace with the increase in MAID cases overall in 2021,” Frolic and Oliphant wrote.
Each MAID provider is taking on more cases, they said, and while that may lead to “sharper skills and deeper expertise,” it also makes the system more fragile.
There have been anecdotal reports of MAID programs across Ontario having to triage people, or transfer them to distant centres for MAID, they wrote.
Nova Scotia put a temporary pause on new referrals last fall after it received more referrals in nine months that it had received for all of 2020, and more than the available doctors could handle, CBC reported.
The program is currently experiencing a high volume of new referrals and a shortage of assessors and providers, Nova Scotia Health said in an email to National Post Wednesday. The agency is trying to actively recruit new team members. “We understand that any delay in MAID can place undue stress on patients and their family.”
In Ontario there are anecdotal reports of people being transferred to distant centres for MAID, Frolic and Oliphant wrote. And the already “morally fraught” practice will face new challenges as the law is further expanded.
MAID is no longer restricted to people whose natural death is reasonably foreseeable. And, as of next March, people whose sole underlying condition is a mental disorder will also be eligible for euthanasia. A joint parliamentary committee is studying whether MAID criteria should be further expanded still, to include mature minors and advance requests.
Many MAID providers already struggled with last year's adoption of Bill C-7, which allows MAID not only for people whose death is reasonably foreseeable (socalled Track 1 patients) but also people with a “grievous and irremediable” medical condition whose death isn't reasonably foreseeable (Track 2).
Track 2 requests often involve chronic pain conditions.
Only a handful of doctors with The Ottawa Hospital's MAID program “are willing to even screen Track 2 patients,” said the program's medical director, Dr. Viren Naik.
“These are complex patients — they've had extensive interactions with the health-care system. Sometimes they're frustrated and angry, which is understandable. Sometimes there are challenges about being very open to a fulsome process,” Naik said.
MAID providers have their own moral and ethical compasses, he said. “I don't think anyone wants to deny someone's suffering.”
But for some, “track 2 is a bridge too far,” Naik said. The expansion wasn't what they signed up for.
It doesn't mean that they're abandoning MAID, he said. Rather, they're narrowing their “scope of practice” to those whose natural death is foreseeable.
But even those requests are increasing. Some doctors “may have put a line in the sand, saying, `This is as much as I can handle right now,'” said Dr. Konia Trouton, vice-president of the Canadian Association of MAID Providers and Assessors.
When MAID is opened to those with a mental illness as of March, “that will be an additional nuance to the legislation that clinicians have got to get their heads around,” said Trouton, including how to do a thorough assessment and meet the medical and legal criteria.
“We're relying on an overstretched group of people to do even more to get into this,” she said.
Many doctors providing MAID don't have expertise in mental illnesses. While safeguards include consultation with a mental health expert, “you're ultimately the one providing,” Naik said.
“The comfort and willingness of the provider, given what they're being asked to do, has to be paramount.”
In the beginning, “when MAID was about metastatic cancer or severe cardio-respiratory illness,” and the person was essentially dying, “the moral distress there is less so — not for everyone, but for MAID providers,” Naik said.
Now, concerns are growing that social determinants of health — inadequate housing, food, whether someone has the money to pay for the medication that's keeping them comfortable — are driving MAID requests.
“All of those are starting to become more touch points, as the expansion occurs,” Naik said.
The association of MAID providers is offering confidential webinars, networking and training modules to try to get more doctors “to feel more confident to wade into this space,” Trouton said.