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- Page navigation anchor for RE: Frail older adults should receive early integrated Palliative CareRE: Frail older adults should receive early integrated Palliative Care
The Canadian Society of Palliative Care Physicians appreciates the detailed commentary “Considerations for assessing frail older adults requesting medical assistance in dying”. It perplexed us that the authors did not recommend palliative care addressing the needs and suffering of those with frailty. The authors referenced a study that identified varied physical (pain in particular), psychological and support needs that would benefit from palliative care, but also noted that patients with frailty are less likely to receive palliative care or die in hospice.
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As noted, in frailty predicting that death is reasonably foreseeable is challenging, especially in those with mild frailty. Not mentioning palliative care for those whose death is “not reasonably foreseeable” raises the persistent myth that palliative care is only for those who are dying in the near future. A good number of studies now have demonstrated that positive patient outcomes result from palliative therapies, particularly when applied early in the illness trajectory. Evidence also supports better outcomes with palliative care in non-cancer illnesses, though research depth lags behind cancer.
It is imperative that all practitioners are aware and willing to incorporate palliative approaches throughout the trajectory of frailty as a means of prevention of suffering. As we know, frailty overlaps with multi-morbidity and in these situations, it often requires a team approach to care that focuses on sympt...Competing Interests: None declared.References
- Sarah Engelhart, Nathan M. Stall, Kieran L. Quinn. Considerations for assessing frail older adults requesting medical assistance in dying. CMAJ 2022;194:E51-E53.
- Stow D, Spiers G, Matthews FE, et al. What is the evidence that people with frailty have needs for palliative care at the end of life? A systematic review and narrative synthesis. Palliat Med 2019;33:399–414.b n
- Zimmermann C, Wong JL, Swami N, et al Public knowledge and attitudes concerning palliative care BMJ Supportive & Palliative Care Published Online First: 07 October 2021. doi: 10.1136/bmjspcare-2021-003340
- Hui D, Hannon B, Zimmermann C, Bruera E. Improving patient and caregiver outcomes in oncology: team-based, timely, and targeted palliative care. CA Cancer J Clin 2018;68(5):356–76. https://doi.org/10.3322/caac.21490.
- Oliver D. Improving patient outcomes through palliative care integration in other specialised health services: what we have learned so far and how can we improve? Ann Palliat Med 2018;7(Suppl 3):S219–30. https://doi.org/10.21037/apm.2018. 05.05.
- Page navigation anchor for RE: Response to Dr Oliver and colleagues on Considerations for assessing frail older adults requesting medical assistance in dyingRE: Response to Dr Oliver and colleagues on Considerations for assessing frail older adults requesting medical assistance in dying
We thank Dr. Oliver and colleagues for their thoughtful response, and agree with the importance of using exact terminology regarding MAiD legislation and policy. Their points of clarification are accurate. They also further highlight the increasing complexity of MAiD assessments and distinct elements of these assessments when people’s deaths are, and are not, reasonably foreseeable.
Competing Interests: None declared.References
- Sarah Engelhart, Nathan M. Stall, Kieran L. Quinn. Considerations for assessing frail older adults requesting medical assistance in dying. CMAJ 2022;194:E51-E53.
- Page navigation anchor for RE: Considerations for assessing frail older adults requesting medical assistance in dyingRE: Considerations for assessing frail older adults requesting medical assistance in dying
We thank the authors for bringing this important topic forward. The relationship between frailty and eligibility for Medical Assistance in Dying (MAiD) requires attention, as the authors state, especially in light of changes to the Criminal Code of Canada, brought about by Bill C7 receiving Royal Assent in March 2021.
We wish to highlight two important points of clarification.
First, the authors state “Bill C-7 also permits MAiD through an advanced directive if eligibility was determined when the person was capable” (E51). The Criminal Code does not actually allow for an advance directive for MAiD; rather, it allows for a waiver of final consent and advance consent. The former is permitted only for eligible persons whose natural death is reasonably foreseeable, and must be accompanied by a written arrangement with the provider identifying a specific date for provision, among other requirements. This act of waiving final consent is later referred to as “advance consent” in the Code. In addition, the Code allows for advance consent in cases of failed self-administration of MAiD medications. These details are important to highlight for two reasons: (1) the meaning of “advance directive” varies from province to province (and is actually not part of the legal framework in Ontario at all), and; (2) advance directives typically focus on a possible future scenario at an undetermined time. In contrast, what the waiver of final consent and written arrangement mea...
Show MoreCompeting Interests: None declared.References
- Sarah Engelhart, Nathan M. Stall, Kieran L. Quinn. Considerations for assessing frail older adults requesting medical assistance in dying. CMAJ 2022;194:E51-E53.
- Criminal Code (R.S.C., 1985, c. C-46) https://laws-lois.justice.gc.ca/eng/acts/c-46/ Accessed January 28th, 2022.
- Bill C-7: An Act to amend the Criminal Code (medical assistance in dying). https://parl.ca/DocumentViewer/en/43-2/bill/C-7/royal-assent Accessed January 28th, 2022.
- "Canada’s new medical assistance in dying (MAID) law" Government of Canada. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html Accessed January 28th, 2022.
- Page navigation anchor for RE: Considerations for assessing frail older patients requesting medical assistance in dyingRE: Considerations for assessing frail older patients requesting medical assistance in dying
As the article points out there are rare cases where "Frailty" in itself (without an underlying pathological illness) is the cause of the patient's request for MAiD. In Ontario MAiD is not mentioned on the death certificate. Unfortunately the chief coroner's office may not accept "Frailty" as the cause of death. Allowing this would facilitate statistical analysis of this cohort.
Competing Interests: None declared.References
- Sarah Engelhart, Nathan M. Stall, Kieran L. Quinn. Considerations for assessing frail older adults requesting medical assistance in dying. CMAJ 2022;194:E51-E53.