Barbara Wand Seminar - MEDICAL ASSISTANCE IN DYING: ETHICAL IMPLICATIONS - June 24, 2024

Good morning everybody. I'm Barry Gang. I'm the Deputy Registrar and the Director of Professional Affairs at the College.
And I'm pleased to welcome you to this Barbara WAN seminar on professional ethics as they relate to medical assistance in dying.
The topic was chosen because it was the most frequently requested topic by members following the last seminar. We're cognizant that college members hold a variety of different views with respect to made.
And respect everyone's right to make up their own minds and be guided by their own values. The information that will be provided this morning is meant to provide registrants and others who are watching.
With information about made to be considered when making their own independent decisions about how to address issues which may arise.
In their work with clients and their families who are contemplating end of life matters. The opinions expressed in this presentation are solely those of the presenters.
And not those of the college.

The events being live streamed with many different devices being connected to the seminar. And most of those devices will be different than each other and they're bound to be a few glitches and some of you may require some technical support.
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Our presenters will try to answer as many questions as possible. At the end of the presentations. If you have any questions about the content of the presentation.
Please use the Ask a Question button near the bottom of your screen. Close captioning of the presentation is being provided and captions can be seen by clicking on the CC button at the bottom of your screen.
In the past, one of the most frequently asked questions has been about continuing professional development credits. Yes, you can, get them.
You can claim 3 credit credits in section B for the 3 h of knowledge. Acquisition today, whether you're listening live or you're listening to the archived recording.
In addition, if you're, watching with a group of people together and just discussing the material, you can also, get available credits in category A.
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In the group, is it registered to the event? Finally copies of the slides are which are being used today will be available after the presentation and they can be found on the Barbara One seminar page of the college website by clicking on the members tab.
If for any reason you still have trouble accessing them, just send us an email and we'll forward the information to you.

So to minimize the number of transitions this morning, we're going to introduce all of the speakers now.

The next person to come on the screen will be Dr. Ian Nicholson, the president of the college who will formally start the seminar by welcoming you on behalf of the Council of the College.
And then in order of appearance, our 1st speaker will be Katherine Morrison. Dr. Morrison's a clinical bioethicist at the Health Sciences North.
In Sudbury, Ontario, she's also the manager of spiritual and religious care and made at navigation at Health Sciences North.
She previously worked as a clinical ethicist at Hamilton Hill, sciences and collaborated with collaborated with ethics colleagues to support partnering organizations in that.
Hamilton Haldimand Brant, Niagara and Lynn. Katherine completed her ethics follow-up fellowship with Hamilton Health Sciences and during this time she had the privilege of working with the Hamilton Health Sciences made team as a made navigator.
Catherine received her PhD in Applied Philosophy at the University of Waterloo.

Her dissertation research focused on the ethics of made and mature minors.

Tony, to Bono. Dr. Dubono is the registrar and executive director of the College of Psychologists of Ontario.
He received his doctoral degree in clinical developmental psychology from York University after completing his pre-doctoral internship.
At the hospital for sick children. Tony or in dual MPs from Queens University and Cornell University.

Graduating with distinction. He's held a variety of clinical and leadership roles in academic health science.
As chief of interprofessional practice at Hamilton Health Sciences. He performed investigations of professional practice matters and a significant experience in applying the regulated health professions act.
Particularly with respect to mandatory reports to regulatory bodies. Tony served as a bioethics consultant at Hamilton Health Sciences and on hospital ethics committees.
Prior to his appointment at the college, Tony was working on transformational initiatives at the Royal Ottawa Health Mental Health Center.
With an interdisciplinary team developing strategic metrics. And modernising the process of obtaining client experience feedback.
20 served on the board of directors of the Ontario Psychological Association in 19, pardon me in 2,022.
And was recipient of the Association's Dr. Ruth Berman Award for leadership as an early career psychologist.
In 2018. And here's frolic. Dr. Frolic is the director of the program for ethics and care ecologies.
Nicely named, acronym piece. And made at the Hamilton Health Sciences and Assistant Professor in the Department of Family Medicine at Mcmaster University.
She has a PhD in cultural anthropology from Rice. University in Houston, Texas, including a two-year fellowship in clinical ethics at the University of Texas, MD Anderson Cancer Climic.
Center pardon me. My sparking collaboration between psychosocial care, ethics, trauma-informed care, and end-of-life initiatives, including medical assistance in dying.
The Innovative Peace Program aims to enhance provider resilience, teamwork, ethical practice, and quality of living and dying.
Andrew's research interests include Made, healthcare worker, well being. Ethics integration from bedside to boardroom.
And developing practices to enable whole person care for patients, families, and providers. Andrew was a member of the Canadian Made Curriculum Development Committee responsible for the development of the national made curriculum.
That launched in 2,023.

Now I'd like to introduce Dr. Ian Nicholson. President of the college, and, will then pass the baton to Dr.
Morris and our 1st speaker.

Good morning everyone. It is my distinct pleasure. That's 1 of my duties as president of the college.
To welcome everybody to the Barbara One seminar on behalf of the Council of the College of Psychologists of Ontario.
Before we go any further. I'd like to make a comment on the Barbara WAN seminar.

That is, Is Barbara Wand and why does the seminar have her name? In the winter of 1976.
And notice went out to the members of the Ontario Board of Examiner's in psychology, the predecessor of our college.
Because of the increasing number of Ontario psychologists, the board had decided to institute a full-time board office.
And we're now seeking the services of a full-time registrar. The salary was listed as between 18 and $25,000 a year.
In June, 1976, the board announced the appointment of Dr. Barbara Wont as our 1st full-time registrar.

Previously, Dr. Wand, have been in charge of psychological services in the Department of Rehabilitation Medicine and was the assistant director of psychology at the Royal Ottawa Hospital.
Dr. Lond resigned on the 31st of May, the 19th 91 saying that she'd held the position for 15 years.
Describing it as a round, indeed that number. During those 15 years as our 1st full-time registrar she took a lead role in the fundamental shaping of our profession in ways that still affect our work today.
In recognition of our work as we entered into a new phase of our profession with the regulated health professions act and psychology act.
The Board of Examiner started an annual symposium on professional practice. Which they entitled the Barbara WAN Symposia.
The 1st symposia in February, 1991 was on psychology and the law issues and professional practice.

The college has maintained annual full day, now semi annual half day events ever since. These seminars have always ensured that we remain current on topics affecting the practice of our profession.
And today's presentation is no different. Today's topic on medical assistance in dying. A topic of particular interest for our profession in recent years, and I'm certain it will be as important as these seminars have been for over 3 decades as our professions ongoing recognition.
Of the importance of Dr. Wond in shaping Ontario's psychology.
Before I pass it on, I would be significantly remiss if I were not to offer a land acknowledgement.
We must remember, recognize. But this land acknowledgement is important, but it's only a part of what our profession must work on in the years to come as we move forward towards reconciliation between the field of psychology and indigenous peoples.
And how we can support the indigenous peoples in Ontario. Today. We wish to acknowledge the land on which our college operates for thousands of years has been the traditional land of the Huron Windat, the Seneca more recently, of the Credit Valley.
Today, this meeting place is still the home to many Indigenous peoples from across Toronto.
And we're grateful to have the opportunity to work on this land. We wish to acknowledge that the land on which all of the registrants of our college operate.
Has been the traditional land of many diverse local nations. And is still home to many indigenous peoples.
We are grateful to have the opportunity to work on it.

You'll see on your screen a listing of resources that can direct you to federal and provincial resources to assist you in better understanding the indigenous peoples in your region of Ontario.
Thank you. And I'll now pass it on to our 1st speaker, Dr. Morrison.

Thanks, Ian. And I'm gonna quickly hand things over to Tony De Bono, to run through a few slides before I start speaking.
Thank you, Catherine. Yes, so we'll do some housekeeping. Of course, really important as Barry has mentioned.
The presentations for information purposes only really important that if folks have specific practice questions contact us at our practice advice service, we'd be happy to chat with you.
And we also have, some, disclosures as well around our relationships to made as we discussed already.
This is a highly evocative and sensitive topic and we certainly want to give it that sensitivity.
Katherine, if you can turn to the next slide please.

We'll start with acknowledgments and then we'll go into disclosures. We will be, viewing a short clip from a much larger interview with.
Well-established clinician in the area who's both an ICU nurse as well as a registered psychotherapist with significant experience working in both of those areas and really wrapping around the ecosystem.
I've made. Her name is Sherri Lin. We'd also like to acknowledge, Roxanne Dylan Court who's a registered nurse, in Sudbury and a colleague of Dr.
Morrison's who's collaborated on education and responding to increasing questions. So thank you Roxanne.
Next slide, please, Katherine. And important to note that we have veering relationships within the ecosystem of made in that folks are going to have varying opinions across the continuum of moral diversity.
And we're going to be sitting with some of the dialectical tensions there. So it's important for us to be very open with.
Our relationship to made and projects that we've been involved with, within the main, service area.

Next slide, some key purpose points for folks. We're going to go over the current state of made in Canada.
We're going to talk about the intersection between psychology and ethics in terms of made, you'll find for shorthand folks we will sometimes be referring to psychology as psychologists knowing of course we have psychologists as well as psychological associates so please bear with us.
We'll also be talking about some tactical or practical considerations around, reflective practice when receiving increase are made.
And we will be going into the potential future of made and mental mental illness as sole underlying reason for provision.
Next slide, please, Kevin. Some important groundwork in terms of what is within scope and what is out of scope.
We're psychology professionals and we're welcoming some of our behavior analysts as well.

We're thinkers, right? And we could think through some really complex considerations around made. We're not going to be talking about the morality of made today.
That could certainly be from any other conversations. We're also not going to be talking about whether or not Made should or should not exist.
Will be in really the moment and presence of what is the current state for our residents of Ontario.

We're also not going to comment whether any specific registrants should or should not provide a made-related service.
Of course, that is a self-regulating function based on your competence. Your knowledge, skill, and judgment.

And lastly, we'll be talking about this concept referred to as conscientious objection. And we won't be commenting on whether or not this said should there shouldn't exist if something is in the law you know must you do something versus not we're not going to be really questioning that we will be talking about conscientious objection though.
Next slide, and I will hand it over to you. Okay, thanks so much, Dr. Devono.
Good morning everybody. Thank you so much for joining. I wanted to kick off our presentation by taking a little bit of time to do an introduction to Made in Canada.
Some of this information may be somewhat familiar to to some of you, but it's important to review because I think it really sets up when we talk about some of the ethical considerations, being very clear about what it is we're talking about.
So I want to start off by talking a little bit about a case scenario focusing on Greg. So I'm gonna read through Greg's case and lead you through a bit of reflection.
So Greg is a 54 year old rural Ontario farmer. Who takes pride in his independence and his ability to care for himself.

He was having problems with what he called twitchy muscles, which led to a diagnosis of amiotropic lateral sclerosis, ALS or Luke Erik's disease.
Greg learned that ALS is a progressive fatal disease of the nervous system that causes loss of muscle control, eventual paralysis, and death from respiratory insufficientiency.
Craig's treatment team included a psychologist who met with Greg at every clinic visit and stayed connected regularly via telehealth.
And despite an initially stoic and taciturn demeanor, Greg nicknamed his ALS specialist Dr.
Non. And he jokingly called his psychologist, Doctor Feelings. Greg, who has worked hard to cop emotionally with his new diagnosis.
And hasn't shared his diagnosis with anyone outside of his treatment team. Dr. Feelings diagnosed him as having an adjustment disorder with depressed mood.
Great was receiving weekly psychotherapy sessions that focused on his depressed mood.

About 6 months post diagnosis, Greg was noticing symptoms of increased fatigue. Balance problems, occasionally slurred words, and a weakening grip.
At a recent care conference with Dr. Neuron and Dr. Feelings, Dr. Neon informed Greg that his condition had progressed to mid stage.
And that he might want to consider moving closer to the city where personal assistant services were more readily available.
Greg was accompanied at this time by his adult son who helps to run the family farm. Dr.
Steel, Dr. Feelings stayed with Greg after Dr. Neuron left. Greg was subdued but calm, deliberate and rational.
He expressed that his disease may force him to live with becoming more debilitated and dependent. Greg took a deep breath and said, Doc, I think it's time to take another trail.
I've read about it and when the time comes, I think I want the needle.

So I want to take a moment to reflect a little bit about this case.

What are your personal beliefs and values about medical assistance in dying hearing Greg's story?
Where do you think your beliefs and values might be coming from? From your culture, religion, life experiences.
Training. There might be other factors that could inform this.
What makes you nervous about Made as a care option? What are you curious about? What might Greg see is a benefit of maid?
How about your own beliefs, values, and concerns? Some of the things that we were reflecting where that might be coming from previously.
How might that impact your clinical practice?

If you were Greg psychologist, how would you respond to his statement that when the time comes, I think I want the needle.
And I want you to keep some of these reflective questions in mind because we are going to be spending a little bit of time talking on how to respond to requests about made.
So what is made? Made is a term that's used in our federal law in Canada, and it's an umbrella term that refers to 2 different kinds of procedures.
So one is euthanasia. This is where a physician or a nurse practitioner administers the medication at the person's request to cause death.
And this is the method of assisted dying in jurisdictions like Belgium or the Netherlands.

There is also a assisted suicide. This would be where a physician or a nurse practitioner prescribes medication at the person's request.
Which the person then would self administer to cause their own death. And this is the method of assisted dying.
In jurisdictions like Oregon or Vermont in the United States. While both are legal options in Canada, euthanasia is the predominant mode of made, with very few cases of assisted suicide, having taken place in Canada.
We're going to talk a little bit about what our latest federal data has shown us about what made looks like in Canada.
And our latest report actually indicated that less than 7 cases came from self-administered made. And this is a trend that's been consistent with previous years.
So as we kind of go through, this introduction and most of our discussions this morning, when we talk about Made, we will usually be referring to euthanasia, although both practices are legal in Canada.
So another important aspect of Made in Canada is how the law has evolved over time. When made was decriminalized in 2,016 following a Supreme Court of Canada decision, Carter versus Canada back in 2,015.
This law applied to capable adults with a physical condition who are near end of life. Although not necessarily having a terminal diagnosis.
The lost scope was actually a lot more narrow than the ruling in Carter. And so there was ongoing societal debate about expanding the law to additional groups.
And some of these groups might include people who are not end of life, but are suffering intolerably with the physical condition, will be referring to this group as track 2 frequently throughout the discussion.
Capable children and adolescents or mature minors. Incapable people who are otherwise eligible but have an advanced directive providing their consent to made.
And last, mental illness is a sole underlying condition.

So while the societal debate has been going on in, 2,021, the law changed to include the track to population.
So people who are suffering intolerably but are not at end of life. And there's been further discussion about schedule changes over future years.
So I know, many of you are probably somewhat familiar with, made eligibility, but we'll take a quick moment to review it.
To receive made, a patient must be, over 18. So they have to be an adult.

They have to be eligible for publicly funded health services in Canada. And so this was put in to avoid medical tourism for made.
They have to be capable of making health care decisions. Again, many of you would be familiar with this already, but I think it's an important point that, having a mental illness doesn't necessarily mean that somebody is incapable.
Of making their own health care decisions. And that can include decisions about made. We presume capacity unless there's evidence that a person is not understanding or appreciating, a particular decision at the time of that decision.
So we'll talk a little bit more about the nuances with capacity and made and mental health later in this talk.
They have to have a grievous and irremediable medical condition. This is a very legal term.

It was written by lawyers, but so a lot of work has been done to interpret what this means for health care providers in evaluating Libility.
But a couple of the factors written out in the law is that they have to have a serious and incurable illness disease or disability.
And right now, the law states that mental illness is not considered to be an illness disease or disability. But I think an important point again is that this doesn't mean that persons who have a mental illness cannot be eligible for made.
They could have a qualifying physical illness along with a concurrent mental health disorder.

In addition, the person has to have an advanced state of irreversible decline in capabilities. They must be enduring intolerable physical or psychological suffering that's caused by their condition.
They need to be making a voluntary request and we'll focus a little bit more around the ethical challenges with voluntariness.
And they have to provide informed consent to made. After having been informed of the means that are available to relieve their suffering, and that includes palliative care, and there are a couple additional options that might also be explored for folk in the track too stream.
So this is when we talk about the tracks. What I'm referring to is part of the made safeguarding process.
So the made safeguarding process is also just, is usually described as having 2 tracks.

This is essentially referring to the fact that there are ease safeguards, for patients who are near the end of life.
And we've, the legal term as their natural death has become reasonably foreseeable. There is a strengthened safeguarding requirements for patients who are not near the end of life.
So their natural death has not become reasonably foreseeable. So I have already been using track one and track 2 when I refer to the safeguarding and I'm gonna continue to be using those terms.
But just to clarify, this is what I'm referring to.

Now to quickly review over the process of safeguarding for a made request. For many persons, the made process starts with an inquiry about made.
Usually what this looks like is an ask for information. Or maybe to be heard, that this is something that they're thinking about and they're finally ready to talk to another human being about, something they've had on their mind for a long time.
Some of the people who might be making inquiries about made may want to make a written request This is the 1st step, the 1st requirement of the safeguarding process, and it does require an independent witness, to witness the written requests and there's certain requirements around that.
We'll talk a bit more about the details shortly. The person then needs to undergo 2 eligibility assessments by independent physicians or nurse practitioners.
There are some additional requirements for people who are in the track to safeguarding streams and we'll review that in a little bit more detail as well.
Then when it comes to the provision. Before the provision takes place, the person needs to be capable and must be given an opportunity to withdraw their request.
And provide express consent immediately before, the procedure takes place. If the person is track one, so if they're near the end of life, and they're at risk of losing their capacity they may enter into a waiver of final consent which would allow the provision to proceed.
If they have been found eligible, but then lose capacity leading up to the provision.

I think a really important point throughout is that throughout the whole process, the person, exploring made should continue to receive the care and treatment that is not related to made.
A person, for example, might not be found eligible, or they may withdraw their request at any point leading up to the provision.
So it's really important that all of their options, all their alternatives to made are still available to them.
And so when we talk about the made process usually there's a focus on the clinicians who are directly involved in navigating that.
But I think of equal importance is all of the health care providers who are already providing the care and treatment that the person's already receiving and may be offering additional options to relieve suffering.
So I wanted to include this slide because I think it's an important point and this is that the eligibility and safeguarding process is iterative.
And that while care may not be escalated, that there is a continuity of care. So that they have all the options available if they're not eligible or if they change their mind.
So asking, about made doesn't necessarily mean a person's going to make a written request.

Requesting doesn't mean that they'll be found eligible. And Elligibility doesn't necessarily mean that the person will go ahead with a made provision.
So here I wanted to just delve a little bit deeper into each of the steps of the safeguarding process.
So 1st I wanted to talk about the written request. Something that's really exceptional. About this step is that it must be initiated by the patient.
Where the client or the the person. So that means that, may cannot be proposed, to the person by a family or caregiver.
They can't request it on their behalf and a healthcare provider can't say, have you considered having need?
This the Ministry of Health actually provides a template for the written request form, which helps the person to complete the necessary information for that step.
And it's actually publicly accessible document. I mentioned to witness, but in addition, there, there's also the option for an authorized 3rd person.
This individual can sign at the person's, direction. They wish to make a written request, but they're physically unable to do so.
So for example, if Greg had advanced ALS, and just could not physically complete the form, he would still be able to go ahead and make that written request.
Many people who make the request, of their, will make the request to their hospital or family physician.

Who have an obligation to make an effective referral if they're unwilling or unable to assess or provide for the person.
Yet something that I think is, you know, not everybody knows is that a person doesn't need to have a family physician in order to be able to start the process.
They can actually self prefer and there is a provincial care coordination service. That gives them that option.
Okay, so as I mentioned, the eligibility assessments must be conducted by 2 independent physicians or nurse practitioners.
Do the assessments usually involve examining the person's medical records and a long conversation, exploring the person's reasons for making the request.
Learning a little bit about the person's concerns, what's important to them, their fears and worries, and making sure that the request is voluntary.
Support of family are usually encouraged to stay for part of the assessment, but might be asked to leave the room to make sure that nobody is influencing the person's answers.
It also involves exploring all of the options available that could relieve the person suffering. For track one, there's no minimum timeline or reflection period since the law was updated in 2021.
But for track 2, there are some. Additional requirements. There's a 90 day minimum assessment period.

The intention is to provide a suitable time for the assessors to explore the relevant aspects. Of the requester circumstances and to identify potential treatment or service options.
For their condition or disability. There's a requirement for a consultant, with expertise in the underlying condition causing the person's suffering.
Although it could be that one of the assessors actually happens to have that expertise. To explore the means available to relieve the person suffering.
And so in truck one, there's more emphasis on palliative care, but in track 2, there's emphasis on additional services.
So this might include counseling services, community services, disability support services, and of course palliative care as well.
Further, the provider and person must agree that the person has given serious consideration to those means. And something to say here is that that's actually a higher bar than, having the capacity to understand and appreciate.
But it's actually, seriously considering. So really appreciate all of the available means to relief suffering and whether they are acceptable or unacceptable to the person.
For both tracks, steps are taken to support communication if there's any communication challenges or the person's unable to communicate.
So now to talk a little bit about the waiver of final consent. So this, as I said before, is an option for track one.
Persons who are at risk of losing capacity. In addition, the waver is actually often referred to as Audrey's Amendment.
And this is after a woman named Audrey Parker. She was diagnosed with stage 4 breast cancer.

And was found eligible for made, but ultimately died earlier than she wanted to because the cancer was moving towards the lining of her brain.
She knew she might lose capacity to provide that express consent for made. It could happen any day and she really feared becoming ineligible and not being able to have the send of life option.
So, based on her advocacy, this, option of a waiver was created and it's really an arrangement that's completed by the made provider and the person.
It allows the person to schedule a provision date and for May to proceed on or before that date if the person loses capacity.
Again, an important point to keep in mind is that for me to proceed, the person does need to be found eligible.

They must make the written requests themselves and be capable to do this and throughout the assessment. Also there is no role for anybody else to request on the incapable person's behalf.
And if I'm going to talk a little bit more about some of the situations that can happen with the waiver when I speak about the provision.
So, okay, the made provision. The made provision happens at a time that's mutually agreed upon by the person and the provider.
Scheduling desk can be an unfamiliar concept and can feel a little bit surreal for the person in their family or caregivers.
But many patients and clients do choose to have made at home. Most people have an idea of what they would want their death to look like.
And plans are usually made with the person to accommodate any special request and to make the experience human. So they might have a preference for certain music, for prayers, for art.
They might have, certain visitors in mind, perhaps family members. Or pets that they would like to have be there.
If the waiver of final consent is invoked for the provision, The provision cannot proceed if the person refuses by and this could be by their words, sounds or gestures.
But this would not include an involuntary response to contact. But if it's, if it seems clear that the person is incapable of refusing, the provision would not go ahead.
Otherwise, the person's given the opportunity to withdraw their request and provide at the express consent. And the person can change their mind or delay the provision right up until the point where the procedure starts.
The provision itself is peaceful and it also happens quite quickly. The person falls into a deep sleep and then dies in their sleep feeling no pain.
The medications administered include a pre-medication sedative followed by an analogistic to avoid any discomfort of administering the medication.
An anesthetic to induce unconsciousness. And lastly, a paralytic that ensures death.
So that there's some certainty.

So a point around, so I described the safeguarding process, in a very generic sense, but it's also helpful to know a little bit more about the local policies that might be at your own institutions.
So many that I have here on this slide are more hospital specific, but different agencies also may have certain procedures that guide how made is practiced, within their organization.
Another important part to, keep in mind as well is that there are certain agencies, and organizations that do not allow made to take place.
Within the organization. And so, some of those organizations will have procedures around transferring persons to another location where they can receive the provision.
And this can cause some challenges. This is one of the ethical issues that we often have come up with made, is the issue of forced transfers and minimizing the harms and disruptions to the person.
So now I want to speak a little bit. We've kind of gone over the process and what this looks like.
I want to talk a little bit about, we've had, made in Canada for 8 years.

What are we seeing? So this is some of the information from the federal report that I mentioned, which provides a profile.
So made rep presents about 4.1% of all deaths in Canada and for context this is around it's around 5% in the Netherlands.
So it's interesting how we are increasingly aligning with the Netherlands for what our made practice is looking like.
Notably, track 2, provision specifically, is a very small proportion of all made cases, only 3.5% of all made cases.
So we'll talk a bit more about some of the complexities with track 2 requests later. We also see that the number of requests is steadily increasing year over year.
Some of the common underlying conditions remain cancer. Most common type is lung cancer. Followed by cardiovascular.
Most frequent is congestive heart failure. Respiratory such as COPD. And neurological conditions.

The most common is Parkinson's. Other is well represented, but to explain this it's usually it's due to multiple comorbidities about a quarter of this group had frailty, diabetes, chronic pain, and autoimmune conditions.
77.6. Percent of the individuals had received polyative care. And among those who hadn't received palliative care, about 87.5% had access.
So it's quite reassuring that that obligation to review all options is very much present. And what we're actually seeing practice to look like.
Another, interesting finding is that the majority of the patients report that they're suffering to be based in the loss of ability to engage in meaningful activities.
This is followed by a loss of ability to do activities of daily living. And both of these exceed inadequate pain control as the primary, description of the nature of the person suffering.
So we spoke a little bit about the timeline before, but I want to acknowledge that, you know, We were kind of speaking about the current state of made, but that there are additional schedule changes that are upcoming.
So one is that in 2 25 Quebec. Is moving to have a the option for advanced directives.

This would be in Quebec only, and so we don't know legally what the implications with this will be is the federal criminal code remains the same.
And in 2027, the law is scheduled to change so that persons who have mental illness as the sole underlying condition could become eligible for made.
So in bringing both of these possibilities up I just want to make the observation that these changes in potential changes have really crowded the discourse on made.
On the one hand, there's a number of recent changes over the last few years that have informed our current state.
But on the other hand, there's been extensive societal debate in the parliament, in the media, over what the possible future state might look like.
And all of this, I think it's really important to focus on what our current obligations to clients and patients that we care for.
Right now.

So, I don't want to spend too much time, but just want to acknowledge that there are a number of federal and provincial resources that have been created to support made practice in Canada.
So, one of these is around, the Canadian Association of Made Assessors and Providers have created a national curriculum.
To train physicians and nurse practitioners. There are also national model practice standards that help to interpret legal eligibility and safeguards into medical practice.
I mentioned there is a provincial care coordination service to help persons making a request be connected to willing assessors and providers.
There's a robust reporting, federal reporting system that's written into the law. And there are certain roles for physicians, nurse practitioners, pharmacists and others who must report made cases to Health Canada.
And this really helps us to understand made practice across the country year over year. In addition, there is provincial reporting to the coroner on all completed made cases and the coroner also has a provincial death review committee that views complex cases and provides guidance and opportunities for quality improvement.
So, our takeaways and further resources, it's important for psychologists to familiarize with current laws and local policies on made.
There is a robust legal safeguarding process. And while mental illness is a sole underlying condition, is not a legal option in Canada, having a mental disorder doesn't necessarily exclude persons from made if they meet all the other eligibility criteria.
Namely, if they have a physical condition that meets the criteria. No physician or nurse practitioners obligated to assess or provide for made, but must provide an effective referral.
And other healthcare professionals have their own college guidelines. And that persons who make a request should continue to receive all of the care that is not related to made and have that continuity of care and that they can withdraw their request at any time.
And I've made the link to topic one of the came out curriculum. This is the foundations of Made in Canada and it's actually open to any health care providers, members of the general public, and provides a really good deep dive into a lot of the content.
I've just covered. So really encourage everyone to take a look. So with that. I will hand things over to Dr.
Dabono to talk about maid and role of psychology.

Thank you. So much. And. Perhaps I'll start by just trying to put words to, you know, this highly evocative topic, I think particularly for us in psychology and the behavioral sciences.
In my experiences working with interprofessionals who have had varying levels of contact with death throughout their professional careers whether it's been in the ICU or medicine units or in oncology.
For us it is I think sometimes it impacts us differently or perhaps there are some different judgments perhaps there's there's just a different experience for us in the mental health and addictions worlds.
I mean, particularly for folks like myself who had dedicated themselves to preventing suicide or the death of another.
There is this interesting dialectical tension that I hope folks can hold because there will be a tendency to move in one polarity or the other.
With these polarizing topics, I do think we have an added duty to society around hyperbolic statements.
Perhaps, at times that not always observing the polarities of thinking and what harm could come about.

Nevertheless though, I think we need to honor and acknowledge the fact that judgments will arise. We use the term patient quite a bit in the hospital system and and really the origin of the term patient despite now the the stigma sometimes associated with the term.
Is about one who suffers. And it's about the bearing of suffering. And certainly when we're speaking of the topic of death, oftentimes the concept of suffering is front and center.
The other thing I'd like to mention before I launch into this intersection between, profession and, and made is that deeply rooted within our social fabric is prohibition against the death of another.
Right, from the criminal code of Canada and, may being a, an exemption within the criminal code.
But also deeply rooted. I'm no theologian, but a very quick scan of the the monotheistic religions when I look to you know the Talmud and the 7 laws of NOAA.
In the prohibition of murder or the Old Testament and the 6th commandment. We're in the Quran chapter 5, verse 32.
There's typically a societal sense of the life force, right? Pushing against this idea of not ending the life of another.
So I think we need to hold these tensions true. Catherine may ask you to present the next please.

So we're going to be chatting about a hypothetical case of course these case details have been modified but we're going to be talking about a client or we'll use the term patient we're gonna be talking about a human being Laurie and about her her lived experience through the process of her her health conditions.
So here's Laurie and Katherine, you'll slowly push through here, but Laurie, 62.
She was referred for a made assessment by her family physician. She's experiencing chronic pain. As a result of an automobile accident several years ago, many of our registrants I'm sure would be working with perhaps.
A client like that within their competence and practice. She was formerly a regulated health professional, a registered massage therapist.
She ran a group practice. As a result of her experience she's unable to work and you know contextually it's important to know that although she lives alone, she has a very close relationship with her daughter who lives, provinces away.
Now she's finding in terms of her quality of life, her experience of pain is increasing her, her, her pain and decreasing mobility, increasing the challenges with that.
Certainly frailty is an issue. And now her family physician in terms of goals and coordination of care, starting to potentially think about whether or not Laurie, would have her needs better, met in assisted living environment.
However, in terms of her values and in terms of what are important to her, her sense of agency, her sense of autonomy and independence is really key to her and part of her, her social history would speak to that.
She doesn't have any other physical illnesses and she doesn't have, according to the legislation, this concept of a reasonable foreseeable natural death.
So in this case, this would be one of those potential, track to, scenarios.

Next slide, please. So what else do we know about Laurie? So she visited her made assessor and again there's sometimes the thought that you know if you see this in the media somebody presents for made and they receive made immediately.
Well of course that's not the case. In this case, you know the physician said let's look at some available options around the treatment of the suffering.
Particularly around the pain. And it's important to note Lori's experience.
So she has visited a pain clinic before and in her experience she didn't see that as being helpful for her.
And then the, you know, the assessor conducted their comprehensive assessment and receiving collateral information and part of the concern was that, you know, they use the, I do this in quotes, the loss to follow-up, but Lori did receive some, some intervention, in terms of her, her ongoing connection with that clinic.
It ended. She had her own, I think, very legitimate and important concerns. Particularly around a family history of substance use disorder and she also discontinued her physio.
So outside of some massage, she isn't, receiving particular treatment. Over and above that of course the complexity of life.
She also has a history of obsessive compulsive disorder. She's noticing a worsening of that.

She participated in some psychosocial intervention. She she received, one trial of medication, she stopped that you decided that.
So what else is on the agenda for Lori? So, the assessor. Dug in a little bit too or got curious a bit to really look into what you know we know that inter professional chronic pain clinics can be in pain claims can be extremely effective you know especially having interprofessional care in this case you know Laurie's thought and opinion was you know that she didn't want medication she didn't
want to become dependent was, you know, that she didn't want medication, she didn't want to become dependent.
But I think the core here is is that she's describing her pain as unbearable. He's describing this experience of losing her independence and and her dignity.
And really this idea that pain is becoming her whole life. So you can really get a sense of this suffering and that she doesn't want to live this way.
So, part of the, the process is, is considering all reasonable options and one of the options, is cognitive behavioral therapy.
So the main assessor was looking into potential interventions around cognitive behavioral therapy by psychology professionals.
And also for the OCD, right? Expression response prevention could be helpful. And she was agreeable to receiving a referral to a psychology professional.
So she sees Jeff. Or she's, she was referred to Jeff and Jeff has it has expertise in chronic pain.
He receives this referral. You know, not surprisingly, he feels a bit conflicted.

So here we are. And I don't know if you folks are experiencing this yourself or perhaps you're already starting to receive these types of referrals in your own clinical experiences.
But I can only appreciate that there's going to be a range of experiences here for folks and reactions.
Next slide. And of course, a slew of questions and feel free to to flow those through, Catherine.
But if, you know, if we were Jeff, maybe we would say, you know, do I want to put in this human being's care if I'm if there's a possibility she's going to die.
As a result of receiving made. What treatments can i offer how can i help right again this then brings up our own sense of duty as clinicians and how do i instill hope right of living a life worth living and having meaning and tying to values and all those sorts of life force drives that we have in our profession.
What about the support system and you know Lori talks about her family but also you know who else is part of her her constructed system there.
Also being very mindful that psychotherapy, you know, works through a collaborative therapeutic relationship and there could be a concern as the clinician that is this person just really trying to go through the steps.
How will I respond if I'm unable to help her? You know, and how is that going to impact me?

My thoughts of failure, my thoughts of futility as a clinician, if I'm unable to help potentially resolve her her concerns.
And how do I manage my own moral and emotional and loved ones? And, and, yeah, happy to go over to that next slide, Katherine.
If you found that the 1st section of this talk was really heavy on legislation and more of the medical stuff.

It's because that's what made is right now. So it's really important to know that psychology professionals are not going to be involved in the direct assessment of eligibility in legislation.
It's very clear that this is a physician or nurse practitioner and very clearly you would not be involved in prescribing or administering medications.
That doesn't mean though that it's not important to know some of that real foundation. Because there's a lot of, I think, sensationalization that can happen within our current social climate.
So it's important to have the core information. It's important to also sit with the fact that in the world of psychology and behavioral sciences, we have potentially a limited scope and role.
But we may see made throughout the ecosystem of care and the varying human beings that come before us and important considerations.
Next slide, please.

So here's just off the top some potential considerations are in your work. You may start receiving referrals where you're going to have to turn your mind to, you know, can I safely answer the referral question in in in place?
Do I have the knowledge, skill and judgment and am I practicing within my competence? You know, what's being asked of me is it capable to answer said referral question like one of the big questions right now in the field.
Not with the current state, but this had even come up with a federal consultations and folks from the CPA had actually presented their Dr.
Get-ins in the Kale, but really talking about some of the elements there around how psychology could be helpful in assessment of things potentially of irremediability or other aspects within that sphere.
These are potential questions that the profession may be asked in the future, but even currently, you may receive referrals around, you know, the fact that psychology has a very important skill set around comprehensive assessment, whether it's neuropsychological assessment, rehabilitation, and you know comprehensive psychological assessments.
Psychology may be asked for a number of different reasons. Clearly speaking about death. You know speaking about that and the concept of suicidality is this important sort of connection.
And psychology, you know, many of us in psychology have expertise in suicide prevention, but also in assessment of risk and assessment of thoughts of death in a very in depth way.
So you may be starting to receive referrals in that in that perspective. Psychotherapy across the span and we're going to be seeing from Sherry Lynn again for folks who are coming in.
She's, she was, she's a registered nurse, worked in the intensive care unit for about 30 years, registered psychotherapist.

She's now no longer working in bedside nursing, but working in psychotherapy and she'll see clients across the continuum of care.
And she'll see clients across the continuum of care. So in psychotherapy, you might see an adult who is a made provider themselves.
You may see a couple or in a relationship where one of the partners in the relationship is exploring aid.
Maybe you're working in family therapy and there's, you know, the child or young person is the quote unquote identified patient, but really it's in the greater context of perhaps an elder, an older loved one who's considering made.
So really there could be a number of intersections where even though psychology the behavioral sciences aren't necessarily directly involved, important for us to know.
And important for us to be aware. And lastly, I'll say, psychology into behavioral sciences in the psychology world, we're oftentimes brought into into professional team support roles or leadership roles and knowledge about made in our intersection, I think will be helpful.
Next slide, please, Kevin.

And here we are in terms of our fundamental values, right? I think at its core in what I've heard a number of clinicians talk about is this inner tension around at the core we want to be doing good.
We want to minimum prevent harm. And this idea that death in any of its form is harm. And we need to be able to sit with that tension because at the same time values can conflict.
And we also have the value of autonomy. An agency and expressed capable wishes of somebody who's fully informed of making a particular decision for themselves.
And really appreciating that concept of the dignity of an individual. Also in concert with relational autonomy within greater context and structure, it's complicated.
And it's highly evocative. And I think despite all the complexity. One of the best things we can do in terms of the best interest of the client is be that safe calm person, be that person to be curious and reflective.
There's going to be enough evocative talk around the table. Psychology in the behavioral sciences I think could be a source of wisdom of reflection and really of treating folks with dignity.
Lastly, and I think what's a really important piece of our work that we're not always faced with the same way as other health professionals are.
Is the concept of utility and futility. So in my work supporting health professionals across the hospital spectrum. When you work in the intensive care unit, it is extremely humbling is what I'm told.
Because despite the best of health sciences, people still die. And it's painful and and you and and there's oftentimes wishes and desires that one could have done more and to save the other.
We have that as well in psychology, but we don't talk about futility and treatment as much actually.

We, you know, historically would blame the client to the patient, right? And, and, and kind of externalize that control as opposed to the fact that every intervention has its, you know, our interventions have their share of evidence and data.
The evidence is limited and in particular individuals in particular context there are some folks who do not get better despite our best treatments.
And that's a hard pill to swallow for us and it is something for us to continue to consider in terms of our intellectual humility.
So as you go for Katherine, you were reading my mind in terms of that next slide. Cause this really is the dialectic, right?
It's, your right as an individual health care provider to have your individual individual conscience.

To conscientiously participate or object which we'll talk about. But ultimately we are working in service of the client, right, of the one who suffers the patient.
There's this interesting sort of dynamic intention that exists and ultimately, your practice as a self-reflecting professional will either help the patient sort of arrive at that are sort of in their best interest or be able to support them.
In terms of their autonomy or you may influence. And that's something that we want to be very mindful of is our is our power differential as professionals.
Next slide, please.

So here's a depiction of the continuum of moral responses. And I'll start with the the far left conscientious objection.
As, we know, as clinicians, and as professionals, we cannot be forced to do something against start will and, and, and it would be unethical and not only would that be unethical, we probably wouldn't be our best selves.
Our most therapeutic in our world, the therapeutic use of self is often times such a key component.
Folks are free to conscientiously object as individuals to, participate in that process. And, and that's a right that I think we need to be able to appreciate.
On the other hand, as we sort of, move up the continuum, some folks may be part of teams that, you know, choose specifically not to participate.
Objectors. Sort of moving into that gray. Then we go into the participation. All the way to some folks.

You know, truly believe that this, you know, the concept of dying with dignity and supporting folks agency and autonomy are such important values that for them they want to support this process and you know there are other areas of health care and medicine that also have their share of controversy where there's very polarizing topics and folks choose to conscientiously object or conscientiously participate.
As they see fit within their within their professional duties. Next slide, please. So really important to note, take home folks for a registrants.
You're not going to be forced to participate in made. Of course, individuals can conscientiously object to, to their participation at the same time.
You're in a power differential. We are in a power differential. We cannot coerce clients.

We also can't discontinue a needed professional services and that's where Katherine was talking about continuity of care.
And if you look at the next slide, Katherine. We see this in our professional misconduct regulation is, you know, part of this the fear and Sherry Lynn will be talking about this in her interview is that they're gonna is that clients will be abandoned, you know, that they feel ashamed to even give words to this desire to die.
Imagine how harmful it could be if immediately after voicing that, you know, there's no effective referral and there's a discontinuation of needed care that could be seen as a potential conduct issue.
Next slide. And you know, let's ground ourselves in our standards through our legislation, our standards, our ethics hold true in terms of sort of these general principles and then applying them to specific case scenarios.
So practicing with in your competence, right, and maintaining that competence. Documentation and informed consent and sound record keeping.
If you work in the area of need, the the legislation really force functions a lot of documentation that folks like Catherine and Andrea are very well versed in, but there's quite a bit of documentation.
The last piece I think in something that I've been attuned to with lots of vocal, I think, discussion about this topic from a range of professionals is compromised objectivity.
And to know yourself. So, are you able to support the care of the client? How do you make sure that your own personal judgments and biases don't unduly impact the clients, autonomous free, capable choice?
How do you do that in a world where we're so highly, evoked right now?

I'll go to the next slide, Catherine. The new standards will continue to talk about professionalism.
So I just wanted to highlight that. So shout out to Barry in the gang. It is dropping next week officially July first, st but the next slide after that, Catherine.
Is around our ethics. And, you know, the, the convention of the CPA was this last weekend in Ottawa.
And lots of discussion around ethics and. Was grounded in our 1st principle in terms of respect for dignity of persons and peoples and this idea of freedom of consent.
And even if we are making social commentary or trying to leverage our social responsibility as Prince of for.
Principal 4 must be accounted for within the greater context of respect for dignity of persons of responsible caring and integrity in relationships.
And given sort of the evocative nature of this topic, we have to be so mindful of our own impacts to our objectivity.
Our job is in service. Next slide, please. This is a just a script that interior into your health uses from British Columbia and really the concept here and folks just a reminder you will be getting the slides after the fact we will be uploading them to the website but this idea of non-judgment and we'll be seeing this in an interview as well, but non-judgment and this idea that care
won't be just stopped prematurely or they'll be in a abandonment of care. But that care will continue.

And really this this concept here is about if folks have questions, how do they go and get evidence-based, information.
Next slide, please. So here's my last takeaway from a psychology specific perspective is that we have a number of roles and we also have a duty at a larger level in terms of sort of thought leadership in this area.
It's valuable for us to reflect on, on our values. This is very difficult work and it's a evocative work.
And we need to acknowledge the fact that this will generate. Judgments, thoughts, and strong emotions.

It's important that, you know, should you exercise and if there are questions around, you know, exercising your individual autonomy as a clinician versus, you know, needs to the client.
Practices devices there and you know you've got other means to consult with you know supervisors and colleagues but certainly I would say using a disciplined ethical approach could be helpful to really reflect and bear public scrutiny.
You'll also find in our in, in our attachments, this values based assessment from the clinical ethics department that Alberta health services.
Really interesting read. You'll see that as a link, fascinating in terms of your own values based assessment.
So we're just at a 10 0 7 and we're gonna go into a short break. So, the break is going to be, let's actually, Mike, can we make it?
It's 10 0 7 a. M. Eastern standard time. We'll make it till 1017.

Alright, so let's plan to get back at 1017 eastern standard time. We will go in a short break for the Parker One seminar.
Thank you, folks.

Hello everyone, welcome back. I hope you were able to enjoy your break. Take a step out, get a drink.
Bio break, whatever you need. So at this point, I want to take a little time to talk about responding to made requests in particular.
I think this is something that a lot of health professionals have. Concerns about managing and what many have already encountered in their practice and likely will encounter, to come.
Okay, so I want us to think back and recall, Greg in the case that I recounted earlier this morning, when he speaks to Dr.
Feelings and says, Doc, I think it's time to take another trail. I've read about it.
And when the time comes, I think I want the needle.

And asking the question, how should the psychologist respond to Gregg? And thinking about how to respond.
The psychologist may have lots of questions. What does I want the needle mean? Is this specifically referring to something like made or maybe talking about pain management is this something else
What does he understand about made? Is he asking about made? A lot of, of health care professionals also might be contemplating.
What grade qualify under the legislation and for a case like Greg's this one was specifically set up to be a little bit more straightforward, but there might be other cases where we might have our own concerns about is this person eligible?
Is this an expression of suicidality? Greg is talking about a desire to die. Or at least we're inferring.
He may be talking about this. Is this desire to die rational? And well considered.
When does the time come? Is Greg thinking about, you know, months from now is he thinking about in 2 weeks?
You know how well considered that ask might be That could change our perception. Is this the 1st time that Greg is talking about this?
Or maybe he's spoken to others before?

Along those lines, does Greg understand all of his options? Is he clear on what might, be able to relieve his suffering?
Has he thought about what might be acceptable to him? And is made really align with his goals and values?
And that's a question that, I'll be, it'll be a repetitive refrain that I'll keep coming back to throughout this section of the presentation.
How is Greg being supported at home? He has a son who helps to run the family farm. But, are there other supports?
That might be there. You know, being in a rural remote setting might pose its own challenges for how Greg is being supported.
Is this an enduring wish? Would Greg maybe change his mind?

And how do I feel about continuing to treat Greg and Dr. Dabono did a really nice job, exploring some of those, considerations.
About thinking about conscience. And what it would mean to participate in providing that continuity of treatment.
So in thinking through some of these questions, there are additional factors I mentioned in sort of the data.
Of what we see. Was made in Canada that the number one factor that was informing intolerable suffering was actually a loss of ability to engage in meaningful activities.
And this comes as a surprise to many people who might assume that it's inadequate pain control, which certainly is also a factor.
And so this gets into when somebody is expressing that they're interested in made or they might be thinking about this option.
What their intolerable suffering might be. We know this might be coming from many kinds of places could be physical, psycho emotional, social, or existential.
And so this is also informing our questions about how what to say in the moment. How do we respond?
And what do we need to know?

So, here I wanted to, as we reflecting on these reactions, touch on, but some of the client and family feedback from the literature has been on the made process.
So many of our clients report being unclear about the process, especially, and specifically how to make a written request.
How to be connected to a physician or nurse practitioner who's willing to provide made. This put some onus on health care providers to help with system navigation and also risk gatekeeping, some of the relevant information.
In addition, clients and, and patients have remarked that they've had to request multiple times before a health care provider responds.
They report that many of their requests are ignored or dismissed. Meeting that they have to make that request a number of times and this can result in some additional challenges I'll speak to in a moment.
There are negative experiences. Unfortunately, of health care providers trying to talk the client or patient out of made.
Common statements might be something like we're not there yet or that would be suicide. Are you sure you're asking about that?
Or you wouldn't qualify if you asked for this. You wouldn't qualify. And importantly, some of these statements are made by staff who are not qualified themselves to assess eligibility.
They don't have that legal role under the law. So we'll talk a little bit about role clarity as well.
Apologize. Put my phone on silent. These statements, might impose moral judgment and can be very stigmatizing, for the client.
Or patient. Many clients lack knowledge about the made process itself and it's it's very common for clients and patients to feel that once they've signed a request form that means they're eligible and that they can expect, that means they're eligible and that they can expect made, you know, to happen at the time of their choosing and that they can expect made, you know, to happen at the time of their choosing.
And it's a surprise to learn about the assessment process and it's a surprise to learn about the assessment process and also that not all providers to learn about the assessment process and also that not all providers are available at any time.
And so it's a bit of a. Negotiation about what scheduling beats the needs of the client or patient but is also sustainable for the made provider.
Lastly, the importance of family and caregiving visiting and this was particularly difficult during the pandemic but highlight some of the harms of local policies that impose additional restrictions.
To clients and families navigating the made process.

And so, okay, that's the feedback. So what does this mean for the client or, and the patient?
What are some of the harms? Well, one is that it can leave out important information about end of life options, leaving, clients feeling disempowered.
This undermines informed consent, which requires that patients and clients are informed of harms and benefits of treatment options.
The consequences of not receiving their treatments and all reasonable alternatives. I also added this diagram from Canadian Hospice Palliative Care Association, which illustrates the importance of early integration of palliative care and early discussion.
Of all end of life treatment options. So saying we're not there yet. It's actually better to have discussions about the options early.
It might actually have the effect as well of impeding access to made. Which could mean that the clients end of life wishes are ultimately not being respected.
For others, this may delay access to made, not impeded entirely, but could actually cause increased risks to the client because they might be forced to navigate this process later in their disease trajectory, which can be very challenging for them with the condition that they have.
They may die before they're scheduled, provision date, despite going through that process to meet all eligibility criteria or that the patient client may go without adequate pain management in order to be eligible through the assessment process, which can be quite distressing for the client, the family, and for and for caregivers, providing support to the person.
The experience of being dismissed by healthcare providers can be very stigmatizing. And can affect their trust as well with their treatment teams.
For, for clients who have a lived experience of mental illness, there's also a risk that asking about made will be perceived as a symptom of their condition.
And we'll talk a little bit about made requests in suicidality later. And the interview with Sherry Lynn actually does provide a little bit of of just kind of the importance of being that safe space so it will be really great to delve into that a little bit deeper later.
And then also to add to this, there might be complicated grief. For, the families.

So the the client having a negative experience is These are harms and of themselves. It is the family that lives on with this legacy and and that might pose additional challenges.
So when a client raises the topic of made, it falls under the role of any health care provider to be able to provide that information to give some resources and to support with the system navigation.
Having these conversations, it can be really helpful to understand the roles and responsibilities of health care providers in the made process.
So in addition to having discussions about Made, there are a number of different health care providers who might play a role in supporting a patient or a client who's exploring made.
The, patient client might discuss their request with their treating physician or nurse practitioner.
So this could be a, family physician or their most responsible physician, for example, or clinician if they present to hospital.
The physician or nurse practitioner may, may choose to assess or provide for the patient client and we'll review this role shortly.
Aside from, from this, the aside from the physicians and the nurse practitioners, no other health care provider can legally decide a person's eligibility.
And we find for many of us who work with made programs, you know, seeing a request come through.
We might have our own ideas. We might have a sense of whether we think somebody might be eligible, but the the client has the right to do process and it is the role of the physician or nurse practitioner to do the eligibility assessments.
Now, if this, you know, you've got a treating physician or NP, They're getting a request.

They are, you know, They might be unwilling or unable to, to. Assessor provide for made.
This could be due to a conscientious objection, but it could also be for other reasons. They might make an effective referral.
So this is explicit requirement, from, CPSO and from CNO. The assessing provider, Physicians and nurse practitioners.
So these are the folk who choose to do the made assessments and the provisions. So I'll talk a little bit about their role.
They might do the made assessments. They can enter into a waiver of final consent with the the patient or client and they ultimately provide made.
There are also some situations, as I mentioned in the 1st part of the presentation, where they might be reporting to Health Canada.
And completed provisions are reported to the provincial coroner. Nurses have a role to play in providing ongoing care and support to the patient client.
And the CNO does specify that nurses can witness a person's written request. And they also have a role to play in inserting an IV line for the made, provision.
Pharmacy and pharmacy technicians have a role to dispense medication for a plan made provision.

They also have their own. Federal reporting requirements. There is an emerging role of a made navigator.
Sometimes this is also referred to as made coordinator. And there are, navigators in both hospital and community settings who are an excellent local resource about made.
This role is held by interdisciplinary healthcare professionals. So in Health Sciences North, our made navigator is a nurse.
But, there are a variety of allied health, for example, speech language pathologists, registered psychotherapists, social workers, and that's just a short list.
The list does go on. Who might serve in this role? And their responsibility is to support clients to navigate the health system and making a made request.
They can help to facilitate effective referrals. And to coordinate the logistics of the assessments provisions.
And they also help to support assessor providers to ensure that safeguards are met. Ultimately it is the role of the physicians and MPs who assess and provide to meet the safeguarding process.
But it's been alluded to before. It's a lot of documentation, a lot to keep track of.

So having a navigator to. You know, help ensure that there's a second pair of eyes on each piece of the documentation.
If everything's spelled out, correctly can really help. There are also allied health who might be part of the process.
They may witness written requests for made. Provide ongoing care and support to clients and The clients may have as their navigating this process ongoing hopes, fears, worries.
Sometimes allied health also play a big role in helping to plan for a made provision. So I'll just give an example in the hospital setting.
We've had patients making made requests who put like to have their pet present and so working through the institutional policies to facilitate, based on compassion that, you know, the visitors that the person wants, that their pets can actually be present. You know.
For their last moments can be really significant.
So I'm just gonna advance forward.

Perfect. So we've discussed about the importance of responding to requests for made. The roles that various individuals might play, but how to have the conversation.
A worry that many health care providers have is that by merely talking about Made, they might be count counseling a client to commit suicide.
And, and of course this would still be illegal. But I just want to provide some reassurance that this is not always true.
An important point to keep in mind is that not all patients and clients know that made, is a legal option, but this might actually align with their values and their wishes and their goals.
And so, and also among those who do know about the option of made, they may not know that it's called made.

They might not know the words to say or how to refer to it. You know, May not be lawyers may not be reading up on the news.
Very closely. So, in these situations where a patient or client is talking about dying, And just wondering about the options that are available to them.
It is an obligation for healthcare providers to inform them. Of course, this can be a careful balance.
We wouldn't want to suggest made to a client or pressure them, especially somebody whose goal, of care is really just to get better and is not necessarily thinking about their end of life.
So a key question I'm going to keep raising this a few times is, is made consistent with the person's values and with their goals of care.
And we might not know when the person 1st brings up. Made. But to answer this, we might need to explore a little bit more about the clients worries and concerns.
And we're going to review a couple of conversational tips
For those who are uncomfortable to have a conversation, it's entirely appropriate to arrange for another colleague who is willing, to have that conversation with the client.
Sometimes, you know, you might have a colleague who is more accustomed to seeing made cases who is comfortable to have those discussions.
Some might be part of organizations where they are well connected to a made navigator. And also ultimately at the end of the day there is the care coordination service which does provide information for clients and.
And of course, you know, we've covered about avoiding pressuring and imposing judgment on the client.
And, document document document, document your interactions. So here I have a quick clip I would like us to just take a moment, which, really kind of delves into some of the.
Perspectives and how to talk to clients about made. So this is Fred Nelson who is a social worker.
So Mike, I'm just gonna ask. To roll the tape. Any health care relationship.

Whatever we do is about what I what I would term in other peoples of term but I've always used this as my motto is a respectful curiosity.
Oh, what are you saying there? And really and tell me if you want to tell me you don't need to tell me but I'm really curious about what that means to you what you just said to me and I'm not sure what it means I'm going to ask you some more questions.
You tell me if I'm going too far with these questions, but I'm just going to ask you.
Where you're coming from and what you're thinking about. And that respectful curiosity and that forming a relationship.
Is really important and it's a mutual relationship because now you're you're you're starting to you're taking an interest in a person you're not there to sort of provide something you're there to really tease out what is happening for this person and what are they really asking me?
Oh, I think they're asking me this is what I'm going to tell them. Oh, I have a solution for you.

You should probably apply for made. That's not appropriate. It's up to us, I think, as health care givers.
To assess what people are really asking for. They may say, oh, I wish. I wish there was I just don't want my life to go on.
I wish it was all over. Well that begs the question to sort of go a little further into that and really help to understand what do you mean by that and where and that could be for family members or the healthcare people to sort of say well Are you are you are you feeling just totally frustrated with with your life the way it is?
Are the things that you want to be different or are you really saying that I want my life to end.

I don't want to go on living this way. Or what are you really saying and what are you really asking to try and you know figure out what people are where they're coming from.
And if they're saying, no, if there is a if there was a If that if that doctor could come in tomorrow and give me a needle to end it all, I'd be up for that.
Then that really opens the door to say, well, actually there is that option. The obligation as a health care professional is to not counsel people.
It's still illegal to counsel people to end their life. That is illegal. But if you're giving them information because they're asking for a resource, then you're obligated to talk to them about that assistance in dying is an option and if you do want to pursue that we can get you information about that.
What it's all about and where you can find that information for yourself. And that's really where that stands.

Okay, thanks so much. So I'm going to advance the slides. And so that clip was from the Canadian Virtual Hospice.
And we have, a few different resources. Though this is one of them. And I really encourage there's lots of really great clips from healthcare professionals talking about their experiences with the made process.
But what Fred was describing as he talked about his experiences talking about made really feeds into some of the conversational tips that we've developed certainly at my home organization at Health Sciences North.
We developed a tip sheet locally to support conversations and This was developed in the inpatient setting, but I included it, but the slides are going to be posted.
So this will be available because it has some useful scripting and a couple of really great tips to think through as you navigate these discussions.
So one is asking for clarification. You know, when you say that you want the needle and to never wake up, what do you mean by that?
And you can also ask, you know, are, are you talking about medical assistance in dying and, and some, you know, clients or patients will say, yeah, that's what I'm talking about.
Alicia the patient's understanding. So you mentioned made or assisted dying or end of life.

What is your understanding of this? Would you like some resources? Would you like more information? It's okay to also make a disclaimer.
So I'm not making a suggestion. But are you aware that medical assistance in dying is an option in Canada?
It helps to provide reassurance that only you can request made. Nobody else will pressure you or make the decision for you.
And ultimately, the biggest tip that, we've given to build capacity in our organization is to follow the patient's lead.
You know, is there anything we can do right now to help you? And You don't necessarily need to be an expert on made in order to talk about made.
If there's questions that they bring up that you feel you can't answer, you know, oh, I actually don't have the answer to that.
But you know, we have, there's a provincial care coordination service. That can provide some information.

We have our local, if you have a made navigator as, as a resource or if there is a made, policy in your organization. Who owns that?
Is there someone to be able to refer to who might have a little bit more knowledge or comfort talking about this and of course to as you navigate all of these discussions to use your professional judgment because it every person is is different every family is different so how they might refer to made, how their comfort level might be will be different in every case.
Now I feel like it'd be remiss to not talk a little bit about, you know, balancing considering made requests and also considering suicidality.
So an important point, I think, to keep in mind is that suicidality can arise at any point in someone's lifespan.
The final expert report on made and mental health clarifies that. The presence of a mental health disorder and other population risk factors don't necessarily translate into an accurate prediction of an individual's risk of completed suicide.
Of course, conversely, a person might express suicidality with no population risk factors, but that doesn't necessarily reassure that they are not at risk of a completed suicide.
So by itself, the general guidance is that may a made request shouldn't be presumed to be evidence of suicidality.

You know, on its own. That said, health care providers should be alert to the possibility of acute suicidality when it comes to, you know, assessing and monitoring risk of suicide, taking into consideration a few factors.
So one is capacity. Particularly if a mental disorder is influencing the person's ability to understand and appreciate.
So the expert panel report gives a really great example about this, someone who might struggle with feelings of worthlessness and self-loathing may not be able to appreciate that death is a harm if they don't believe they have any value as a human being.
Another is ensuring that the person's request is consistent with their values and beliefs, that it's unambiguous and it's enduring.
You know, does this sound like what I know this person to be? I find sometimes we meet. You know patients and clients who are who are asking about made And, you know, as you're speaking with them, it's very clear that this is a deeply held belief that they've held for a very long time.
But if it seems like it's really out of character for the person to be, you know, saying these statements are asking these questions.
But that might be taken a little bit differently. Other factors might be the person's past behavior, whether there's an untreated or unstable psychiatric disorder, whether the person is made references or illusions to wanting to end their life.
They have plans or actions that, to further those plans. And of course it goes without saying that during an episode of Acute Suicidality, health care providers should be focusing on mobilizing individualized suicide prevention efforts and considering the types of interventions that might be helpful.
You know, offering negotiating therapeutic options. Conversations about Mage should be avoided during this time.
So considering the timing, right, for when to have conversations about MED.

Okay, so having said all of that, so where does a client go to complete their request? Well, any person can access and complete the written request form on the Ministry of Health forms repository.
And I've linked the form into the slide. I also mentioned a couple times the provincial care coordination service and anybody can call through Health 8 1 1.
And a made nurse will call the patient or client back to review with them some information and to be able to help to refer to them to assessing providing physicians and nurse practitioners.
In addition to this, there are coordination supports at the local level. And the regional level and it would be beneficial for psychologists to familiarize with their local resources.
In some regions there's a care coordination, through home care, community support services, and in others it might be through a family health team.
Many persons, they don't need to go to their family physician, but many do. And that's their 1st 1st stop or when they're admitted to hospital and they're talking to their hospital team.
Okay, so takeaways and further resources. Patient and families report significant impacts when health care providers refuse to hear their requests for made.
So it can really speak to how having these conversations is so important. Any health care provider can offer information about the made progress, process and resources can support with system navigation and can we also refer to colleagues who are more comfortable to have the conversations.
And it's beneficial for psychologists to be aware of the provincial and local pathways and in your area in order to request made.
And so I've left the Ontario Ministry of Health website. This is a great information for patients.

Resources that we often actually give to patients who are asking about Mate at Health Sciences North.
And I also link to virtual hospice for more resources in addition to that. So with that, I will pass the baton to Andrea.
And I am going to. Approve remote. You are in control. So much, Catherine. And good morning, everyone.
It's great to be. With you this morning, thank you for making time and your busy clinical lives and schedules to.
Really, absorb and reflect on the complexities of the intersection of made. And psychology practice.
So.

Alright now I'm having difficulty moving forward. There we go. So there are lots of, ethical challenges that arise in made practice.
You've heard about some of the legal criteria you've heard about some of the challenges in responding to the initial requests were made by patients.
We did an informal pool at a recent national meeting of made assessors and providers and we asked them what are some of their ethical issues that they experience in practice.
So I wanted to give you a sense that even for those who've been doing made practice for many years, you know, it's been legal in Canada for 8 years now.
Clinicians still report appropriately a number of ethical challenges that they encounter as they engage in assessment and planning for main provision.
So lots of challenges related to complex capacity assessments that people report. Wondering if the patient is actually giving serious consideration to other options or if they're choosing made.
Perhaps prematurely. SIM providers are concerned about the risk of suicidality, not just about, related to the patient's initial made request or assessment.
But when patients are found ineligible for made. Sometimes patients will say, and make threats that they will actually harm themselves.
So. Made providers and assessors really have to be alert to how to support clinicians. That, sorry, help to support patients and their families when they're turned down for made and how to really provide wraparound services in support.
To help that person adapt. To their new reality and to explore other options to support their quality life.
There can be very challenging interpersonal dynamics. Sometimes you experience family members who are really opposed to the patients.
Exploration of made. Managing wait lists in many parts of the country. There are long wait lists.

Especially for track to patient. Who don't have a recently for steeple natural death and how should make clinicians manage and triage their weight list.
At the assessment of volunteeringness can sometimes be challenging, not so much that. Family members are necessarily trying to pressure the patient toward made I've actually never experienced that in the dozens and dozens and dozens of patients that I've, supported in the process over the last 8 years.
But sometimes we question whether there's a internal motivation. For example, internalized shame, a sense that, a person doesn't deserve to continue to live that might actually not just impede their capacity, but also their volunteeringness.
And then managing the stigma of being a made provider, many of us don't talk very openly even with our own family about our work in made because it's still somewhat of a taboo area of practice.
And also we encounter challenges with conscientiously objecting, colleagues. And sometimes there's tension in those inter professional relationships that have to be managed.
And then supporting the privacy of patients and families, especially in rural remote communities where everybody knows each other, how to really ensure that you're honoring the privacy of patients in within their small tightenit communities.
There are also of course you're already thinking of them and anticipating them throughout this presentation, ethical considerations in your practice when Maine arises in your clinical practice as something that your patients and clients are exploring.
So just confronting the fact that not all Canadians have equitable access to psychological and behavioral health care and how do we lean in to advocacy and also lean in to, filling some of those gaps when we identify that a patient could perhaps really benefit from psychological behavior.
Stepating the mental disorder from the physical ailment. So, we're gonna talk about Laurie's case, which Tony walked us through earlier, which part of, Laurie's desire to die arises from her chronic pain condition and which part might arrive from fermented disorder or the mental sequel I that arise from having chronic pain, perhaps anxiety, depression, that existential suffering, et
cetera. How to pull those apart and how to treat them concurrently in an effective way. Identifying, as Tony said, when psychological treatments are a few child, the patient has tried everything and in spite of all the things that they've tried over many years.
Sometimes they're symptoms remain. Refractory and, and really impede their quality of life.

Identifying when psychological suffering is therefore, you're, more, appropriate or available treatments.
That could potentially change the patient's course. Or that the patient finds acceptable patients are allowed to decline care, especially if they've had negative experiences in the past or they have side effects that are unacceptable to them.
And sometimes we encounter patients who are inconsistent. They show to half their appointments, but not all the appointments.
We might question is that decided that they're not capable and are they really trying treatment in good faith?
What do we what do we do when we feel like maybe a patient is sort of showing up pro, but not really engaged in a therapeutic, relationship with us.
How do we manage the fact that in all areas of practice, clinicians have divergent to peer, opinions about the same client?
So what if you have a family physician you're working with who believes the patient is eligible and another specialist, who believes they're not eligible and they want you as a psychologist to weigh in around some aspect of their eligibility.
Like the patients capacity or whether their psychological suffering is irremediable. Patients, who don't want a true, treatment at all.
They just want to die. And how to work with that, sort of resistance to engagement.

So how do you know that there is an ethical issue that you're encountering of practice? There's lots of clinical complexity in this domain.
But there are some distinctive, I think, symptoms of ethical issues. So the 1st is to really pay attention to what we call your own yuck factor.
That's often an embodied response to a patient scenario. Maybe you feel that tightening in your chest or heaviness in your in your head or clenching in your guts.
Often your body knows even before your very clever brain knows that you're encountering something that's challenging for you.
Morally, or ethically. So paying attention to your own yuck factor. Team conflict or divergences of opinion amongst a close net team are also sometimes signs of an ethical issue or values conflict.
Sometimes you're in a bit of a damned if you do damned if you don't scenario on the one hand offering made has these harms potentially to a patient but not offering it or not pursuing it actively with the patient may also have its own harms, ie, a patient remains in intractable suffering indefinitely.
So how do you really balance those harms and benefits? Sometimes there are conflicts between values or conflicts with our organizational values versus our personal values.
For example, how do I continue to lean in with compassion to my patient? But also honor my own right of functions and the fact that for this particular patient, I don't feel like made is the best option or one that I can in good faith, support.
Sometimes there's a big ambiguity in the law, or ambiguity in the application of the law or ambiguity and how we apply our own policies.
And then the experience of moral distress. You know what the right thing to do is, but there are systemic barriers or institutional barriers that make it impossible to do the right thing for that.
So these are all signs and symptoms of an ethical issue to be alert to. And I'm gonna talk about, you don't have to just blunder endlessly in that kind of moral quagmire, but there are specific tools and resources that are designed to help clinicians and their colleagues along with their patients and families.
And to move through these moral quandaries. Tool that many organizations and clinicians have found useful is an ethical framework.
So an ethical framework provides a rigorous process that helps people to identify relevant values and think about how to apply those values to specific patient scenarios.
An ethical framework is designed to both pay attention to our get responses, but also to slow decision making down a little bit.
To pause and reflect on key inputs into ethical decision-making, like getting the facts straight, sometimes our ethical or moral concerns come from the fact we don't have all the relevant information.
Really identifying the values and also, seeing the trade-offs and conflicts and tensions between those values.
Making sure we open with curiosity to multiple perspectives. The perspective of the patient, the family.

Our clinical colleagues. And the perspectives of others who are surrounding that patient and family. And then thinking about what are the consequences of different options and being open to weighing the pros and cons of different options.
So, and the ethical framework is designed to consider and map all of these factors to way farms and benefits and to bring a kind of ringer and consistency and transparency to decision making.
My experience as an ethicist for over 20 years is that even if people don't agree with the decision made at the end.
If they feel that the process of decision making was fair, rigorous, evidence-based, transparent and included a variety of perspectives and values.
They're more likely to be able to live with the decision and support it, even if they don't personally agree.
So there's an afternoon for everything, including an ethics in our practice and the acronym that we use that kind of sleeves out the step by step process, the ethical decision making of Hamilton Health Liances is called issues.
So the steps are 1st you identify the other collision stakeholders, you study the facts. You select the reasonable options, you understand law, values, and duties relevant to the situation.
You evaluate the options you've identified and justify your choices and then the plan moving forward. There are other ethical frameworks.
That you may have in your institution, Accreditation Canada requires all healthcare institutions, hospitals specifically to have an ethical framework that they use and put into practice.
So if you're connected to a hospital or institution, I encourage you to pull out your own ethical framework and think about how you might apply the ethical framework in your own practice.
Some hospitals use the idea of framework, some hospitals, the intention impact tool and there are many others. Minute they're all the same in the sense that they really focus on these factors of identifying the issues.
Identifying the stakeholders, studying the facts. Selecting options thinking about values and duties evaluating options and justifying choices and moving forward.
So we're going to talk about how Jeff might use an ethical framework like issues and to help him and his colleagues think through some of the ethical dimensions of Laurie's case, which is the case that Tony walked us through the little synopsis of at the beginning.
So first, st what are the ethical issues involved in receiving and responding to this referral and consultation to support Laurie's made assessment and her care going forward.
So Jeff might be thinking about to what extent is Laura's psychological suffering contribute to her contributing to her chronic pain?
Is it renewable through treatment that is acceptable to her? She's already said no to a variety of treatments offered by the chronic pain team.
So really getting into exploring what are the options that are available and might be, acceptable to.

And if Jeff is uncertain about his own feelings about made, how might his ambivalence impact their therapeutic relationship?
How does he manage those? And what is the right way for him to engage with Lori's case in good faith?
Honoring his own feelings. And honoring his duties to Laurie, to be that non-judgmental and safe space, and to offer his best efforts in terms of supporting the exploration of options and to consider how Jeff might engage with all of the stakeholders involved in Bory situation.
So Lori herself, perhaps with Laurie's consent involving Abigail as her primary support person.
Connecting with the made assessor as well as the family physician and other members of the care team.
So when we're thinking about all of the facts, that are important to consider around a case like this, Jeff would want to spend some time reviewing Laurie's health record and getting clear for himself on whether her diagnosis.
What are the treatment options she's already explored and treatment options that Jeff may engage with her? How has she responded to treatment in the past?
How might that inform? How Jeff approaches the therapeutic alliance with Lori. Maybe spending some time with Laurie in the initial assessment process, understanding her goals and wishes and fears and beliefs and also understanding how her own cultural and social context is informing her experience of her disability and own pain condition and her motivation to seek need.
Jeff also needs to do his own homework around ensuring he is aware of the made legal and regulatory context.
It's not that made, it's not that Jeff is a made assessor in this context, but it's likely that Jeff's engagement and documentation and reports about Laurie's case could be used to support the made assessor judgment about her eligibility.
So being really clear about how that made assessor may use some of Jeff's cynical notes.

And also conversations with Jeff is really important. To understand, for example, would Laurie potentially meet the criteria of grievous and your rematable medical condition under attract 2 criteria and safeguards?
To what extent might her capacity be influenced by her OCD or her chronic pain or both?
And thinking about has Lori really given due consideration to all treatment options and that was something that would be assessed over the course of their relationship.
It may be helpful for Jeff to reach out to other members of her clinical team. To, understand how the family physician and made assessor are approaching, their assessments and support for Lori, but also for just to himself reflect on, can I give unbiased care to Lori?
Can I safeguard our report in spite of my own ambivalence or fears related to my involvement in Laurie's case.
And what supports do I need as her psychologist and to process my own feelings and really thinking about your own support system as a psychologist and activating that.
And then exploring the systemic issues. Does Lori have access to other community or support services to improve her coping and her quality of life?
So then it's important once you've studied the fact to think about, okay, what are the options here for me as a psychologist in terms of how I might engage with this consultation.
So 1st it is an option for Jeff not to accept this referral or to do an initial intake with Lori and then upon reflection say you know what I'm going to make a referral to another colleague.
It's also an option for Jeff to accept the referral and then very narrowly and specifically engage with Lori about treating her OCD and her pain coping.
But not to engage any aspect of the made process. Or another option. Might be for Jeff to accept the referral and of course focus on his goal in focusing on supporting.
Her coping related to OCD and paying. But also a willingness perhaps to engage with the multidisciplinary team around her made assessment, including supporting the assessor in understanding whether she's has capacity to make an informed choice between made and other options.
To Seth, whether she meets the criteria of a grievous and irremediable medical condition and exploring her community and familiar supports with her family.
So 3 options. You may have thought of other options that, Jeff may also consider in engaging with, So then in thinking about, okay, those are some of the options in terms of my engagement as a clinician with Laurie.
What are some of the duties and values I need to be aware of as I explore the different dimensions of my relationship with Lori.
So 1st of all, we've already talked about the importance of not abandonment. And being mindful of the significant emotional and psychological, to patients who feel abandoned in the process.
I have met patients and families who have experienced true trauma from, conscientious objectors who made the patient family feel shamed about their desire to explore the option of made or who immediately signed off of their care without really making an effective and warm hand over to another willing clinician.
So really being mindful of how our own handover and referral process may be perceived and experienced by patients and families.
Of course, the value of beneficence, how do we really get creative? About all the different options that might be available to Laurie.
We know that she has real reticence in taking opioids for examples or other medications because of her history, her history of substance use disorder in her family.
How do we be sensitive to that? Perhaps other not addictive medications and options for her. What about her autonomy honoring her right to refuse treatment?
As well as to choose a path that aligns with their values. And equity and advocacy.

So what is our role as health professionals when we know there are gaps in the system? To really advocate.
In partnership with our colleagues to help Lori cope with her disability in her new life circumstance.
And, Bal's getting this thing around having a whole person care approach and recognizing, but Laurie doesn't, you know, exist in isolation.
And perhaps encouraging, to draw in members of her support, Cisco like her daughter Abigail, of course, with her support and and permission to really create a plan of care that that honors all of the dimensions of Laura's suffering but all of the dimensions of Lori's resilience she's been a very tough person over the course of her life and and how to amplify her
resilience. So evaluating options justifying choices in the end, theoretically Jeff may choose to accept the referral for Laurie and so then what?
Perhaps he spends time educating himself about made since this is a new experience. Maybe he reaches out to colleagues who he knows has, it have experienced navigating the main process personally and professionally.
So he understands his duties. He might choose to focus on her kind of pain, but also engage with her around conversations for the quality of life and her existential suffering.
And he may in fact ask to meet after the course of her CBT is completed or it comes to our natural stopping point or milestone.
And reaching out to the family physician and the May disaster say, can we meet together? I'd like to share with you with Laura's permission, what my findings are, how I think she's doing and what I think, her treatment options for her psychological stress might be going forward.
And then supporting the plan theoretically, perhaps Laura does experience significant benefit. Often I have noticed that track 2 patients that I've been following to have counselors psychotherapy and psychologists who lean in to address the psychological dimensions of their suffering.
I have noticed that they experience from markable improvements. In their quality of life and in some cases our track 2 requests have simply gone away because the psychological stress of the patient has been very effectively attracted.
By people holding their psychological and existential distress. So perhaps in that case, Lori might experience a lot of benefit and relief.
Suffering, and perhaps she starts to explore an option of moving closer to her support system.

Her daughter Abigail in Halifax. The main assessor might opt then to put the made request on hold to give her more time to benefit from psychological treatment and support systems.
And he might offer to transfer care to a colleague in Nova Scotia if she chooses to pursue it in the future.
The family physician offers to connect Laurie and Abigail together to a social worker in their clinic to help them explore options for Laurie's long term housing and support options when she moves to Nova Scotia.
And then Jeff might complete the handover to the family practice team and offer to provide peer support to other psychologists navigating the made request going forward.
So there are many many ways that this case could but this is just one example of how that issues framework could be completed and Jeff could continue to support Laurie and her clinical theme going forward.
So it's important to recognize sometimes we feel a lot of, shame when ethical issues arrive in our practice because we think, wow, I should I have a PhD.
I'm smart enough. I should know how to navigate these complex cases or, I have 20 years of practice.

No, what to do in this case. But made is new for all of us and perhaps specifically new, 4 members of this community.
You haven't encountered yet in your clinical practice. So offering itself a lot of self compassion and recognizing that ethical issues are not unusual.
That they're an indication at not at all of incompetence or weakness. That they're not something to fear or deny or avoid, but rather to really open to with curiosity.
That ethical issues are not just about your personal opinion or gut instinct, but really require that kind of rigorous approach.
They're not unresolvable. But they are resolvable. And they're also not resolvable by means to just rules or evidence alone, but they require this kind of systematic.
Both factual and ethical form of reflection. So at the, are an expected part of complex clinical practice.

They are a sign that your own moral consciousness is very alive and well. So I always think it's something to celebrate when we encountered the in practice.
There an opportunity for deepening reflection for professional growth and for team building in connection with one another. They're anchored in a diversity of values and principles, evidence and guidelines that need to all be balanced and considered.
They are best addressed not by just going with your gut, by engaging in systematic and standardized and multidisciplinary analysis.
They do require mindfulness and pensions and the drawing in of collective wisdom. Benefits of using issues framework or any other ethical framework.
To mitigate our biases conscious or unconscious helps us to consider multiple perspectives and options supports evidence-based choices and considers these trade off between values.
To promote our mutual support and learning within our team. Helps to, support transparency and reflective practice may also be helpful in our documentation of our complex.
To really be able to document that we have engaged in a rigorous process of reflection with our within ourselves.

And with our teammates. And can at least help, to resolve. Conflict in a constructive way by making sure all voices and perspectives are heard.
And in the end, we hope that it helps to diminish our moral distress and prevent moral injury. And again, deepen our growth as clinicians.
There are other resources to help you address ethic beliefs in your practice aside from, ethics frameworks.
You might have mentors who have encountered these kinds of issues before. You can reach out to your peers support network.
Some of you are meeting in groups today to watch this. Webinar. Well, you could consider that an informal peer support network.
There are often ethicist or ethics committees attached to your healthcare institutions that you can access for support.

There may be other institutional supports within your health system like risk or legal. Council or DEI resources if you think there's an equity diversity and inclusion aspect to this case and of course you can reach out to the folks here at college.
So take away and further resources that you might consider, reminder that as we said many times, although you cannot be a made assessor or provider or prescriber to defense medication to remain, you have many important roles to support patients.
We're navigating. Modeling with questions about whether they should continue to live or whether it's time for them to let go and choose a peaceful ending to their life.
Ethical issues are a normal part of your practice every practice and it's important to identify them, get support and get structure to help you work through them.
One structure can be an ethical framework. And then when you, might exercise your right of conscience, it's important to follow your college guidelines, particularly your duties surrounding transitional care and effective referrals.
You really want to acknowledge to, that my experience working with clinicians over the last 8 years is that while I might experience a contact, subjection to one case.
Another case down the road I might actually be an anxious participant. Because sometimes our feelings or gut instincts or moral responses to cases are very specific and contextual.
And so be alert that even though you might need to step away from a, there may be other cases in the future that you think, gosh, I really do have something to contribute to this patient's care.
I think I could establish an appropriate therapeutic record with them. And I do feel like maybe I've matured, and I'm prepared in my own practice just to lean in in a different way.
So, remaining open and curious through your career to what the many different gifts that your clients and patients can bring to you in terms of your own growth as as a.
So I think we're taking a break now. And then we're going to return and just spend a couple of minutes talking about Made and Mental Endless is the so underlying condition.
I want to emphasize as Katherine has already done, this is not currently a legal option in Canada. So with this talk it theoretically about some of the issues and values that need to be considered.
If this does become an option for Canadians.


Hello. Welcome back. I hope you had a good bio break. So we're gonna talk a little bit about made and, mental disorders.
That is the language that is actually used in, a lot of the regulations. So, if you don't like that term, I, that's the language that's commonly used in thinking about how, mental illness.
It manifests in the made space. But just to remind you that Currently it is not a legal option in Canada for persons with mental illness as the sole underlying condition.
That is motivating the request for made. That is not a legal option in Canada because there's very specific language in the criminal code.
That's it that a mental disorder does not count as a grievous and. This is been hotly contested.

You pick up any newspaper. not that anyone picks up a physical newspaper. Actually, Okay, What a contracted area this is.
Mental health advocates are on both sides. Of the debate some people saying that why are we stigmatizing people with mental illness and pretending that they don't have the capacity to make this decision when they have capacity to make many other decisions about their health and life.
So is it a form of discrimination against people with mental disorders and other people on the upper opposite side of the spectrum will say that the impact of having a mental disorder can potentially make a patient ineligible because it may, their capacity or their voluntariness.
And there are questions about, the, the ability of, treatment related to mental disorders. So I'm gonna talk just for a very few minutes about.
The possibility and prospect of having. Made for mental disorders is the sole underlying condition. Currently the parliament has put back.
The option to have made for this population 3 times now it was pushed back when the initial made legislation was passed in place.
And then it was back again in 2021. These patients were supposed to gain access at this past March in 2024 and then parliament pushed it back again to 2024 and then parliament push it back again to 2024 and then parliament pushed it back again to 2027 so before the next 3 years that's it back again to 2027 so before the next 3 years, it back again to 2027.
So for the next 3 years, this remains purely a theoretical option. But I think it's worth recognizing.

That. I think it's worth recognizing that it may. Come up in your practice because many patients who have a grievous and, a, in a, medical condition also have a concurrent.
So what can this look like? Here are some examples of patients that I've seen or patients like this that, are made practice and colleagues across the country have described.
So a stage for cancer who is a cancer patient who is experiencing anxiety about their future pain. And ALS patient who has significant depression, perhaps related to their coping with their increasing disability.
I see a PD patient who has bipolar disorder. That may or may not be well controlled, but it's the COPD and they're suffering related to their pulmonary disease that is driving their made request.
A patient who is dying from liver failure but who has a remote history of suicide attempts. And a patient who is chronic pain like our case of Laurie.
Who has a significant trauma history and that trauma history may impact their ability to have hope, their ability to engage in a therapeutic alliance with their care team.
So it is true that currently patients with significant mental disorders are already accessing MED. But it is the case that they have another physical ailment and sorry for the polarity between physical and mental illness.
I recognize that all of those exist on a continue on influence one another. But it is not that I'm common to, meet patients who have both kinds of issues and disorders and ailments.
So how can we and you as a community psychologist, to support your connection colleagues, your physicians and your partner colleagues who may be engaged in assessment of these patients.
But also the patients you encounter in practice who have a mental disorder and who are exploring made as a potential option.
1st of all, I think this community has an incredible role in helping to de-stigmatize people with mental disorders and advocating for equal treatment.
It remains sadly the case that many people who have a mental illness are labeled as incompetent and capable of directing their own care not able to make their own informed choice.
So really the stigmatizing and empowering patients. Take hold of their own futures and enact their own economy.
Reminding colleagues that having mental disorder does not make someone incapable of making informed choices promoting psychological health and quality of life for patients who may be experiencing failing physical health.
So even as a patient is exploring the option of made even if they've been found eligible for made.

There is still so much that you can do to improve their quality of life as they anticipate their dying process.
Supporting, for example, reconciliation with families supporting. Life review and life reflection, supporting addressing existential stress or spiritual distress.
And again, that relates to your role in supporting the whole person approach to care, which might include couples therapy or family therapy as patients approach the end of life.
And of course we have to remember that clinicians are also clients. So you may have clinicians who are your clients in your practice who are involved in made as a bedside nurse as a made assessor as a pharmacist.
And they may also come in asking for support. But in your clinical world, you may be an interprofessional teams where you are asked as Jeff was in our case, to support the made assessors at their thinking through the complexities of is the patient people is the request voluntary?
Is their psychological suffering, remediable or irremediable?

So there are a lot of already off question about made for mental disorders alone. Recently, when the federal government made the decision to.
Or patients who have mental disorders for underlying medical condition until 2027. They release parliament did a series of hearings between October and January of this past year and they released a report of the findings.
A summary of the findings of those hearings and it's called made of mental disorders, the road ahead, we can link that as a resource.
And there were a couple of reasons based on testimonies that they had heard from various. About why they made the decision to wait, to make this option, accessible until 2027.
One, rationale was the lack of consensus within the psychiatric community about, whether the system is ready for me and whether may, mental disorders are in fact, ever going, in, in their nature, lack of consensus about prognostication and the accuracy of prognostication.
Lack of running, then accent within the mental health system, concerns about vulnerability, patients with mental disorders.
And whether they could be potentially induced, to, request or receive name and then difficulty as I said around.
FROM, the, in, in, inability, for people in who are experiencing mental disorders.

However, we have to recognize that there are lots of other conditions that people are eligible for. However, we have to recognize that there are lots of other conditions, that people are eligible for made where, there are lots of other conditions, that people are eligible for made where, there are questions or challenges related to incurability and reversibility.
There are questions or challenges related to incurability and irreversibility. And we use expert judgment and challenges related to incurability and irreversibility.
And we use expert judgment and opinion and clinical judgment to address those. There are certainly concerns about capacity assessments, especially for patients who have waxing and waning symptoms and who maybe have inconsistent requests for made, how do we reaffirm their capacity through a series of conversations over time.
The question about is a desire to die ever rational and well considers especially for persons who have proactory symptoms.
And then as I mentioned, the parliamentary report was very concerned about structural vulnerabilities. We have to recognize though that the global evidence tells us that Made is accessed by the privileged almost exclusively.
The overwhelming over 90% in every jurisdiction were made is a legal option over 90% of people access made or white.

And people tend to be highly educated. Well informed and tend to have come from a fire socioeconomic bracket so there is no evidence that made is exploitative of the vulnerable.
In fact, quite the reverse, it appears that people who might have a, be equity, parts of equity deserving populations or groups has difficulty potentially accessing made even if it's an option that they would find acceptable.
So how do we find this balance between supporting access for people who are part of equity deserving groups, but also protect.
Folks from potential, vulnerability or so there are some considerations that Parliament, has requested and recommended in terms of the lead up to 2027.
1st of all, they're actively engaged now in consultations with 1st Nations, Metian, Inuit peoples about their needs related to ensuring that MAID meets their needs culturally.
And legally. There is a request for further engagement with person to have lived experience with mental disorders There are questions about whether we need to augment the current.
Made practice guidelines with additional safeguards for guidelines specific to people with sole underlying mental disorders as they're using for requesting.
They have questions about whether there needs to be tighter monitoring. In an additional oversight for this particular population.
I think it's really important that I want to congratulate the college that one of the concerns that's been raised is how do we support mental health workers who are responding already to requests and increase about made from their clients and how do we engage in proactive preparation.
To receive these requests and for the eventuality. When made becomes an option for people have a mental disorder as their sole underlying medical condition.
And so with that in mind, I'm gonna turn it over to Tony. And and write us to reflect on one clinicians experience in responding to patients families and providers who touch them.
Incomes made. Thank you, Andrea. And I'd like to preface this by thanking Sherry Lynn, RNRP for folks who weren't present at the beginning of our talk.
Sherry's a clinician in the field. He had worked as an intensive care unit nurse at the bedside for decades.
Went and became retrained and became a registered psychotherapist. As well and now she's providing care in the psychotheraputic realm to many different folks in different contexts.
So it could be the individual client themselves who is looking into made and that happens to be part of the therapeutic journey.
It could be in relation to relationships, whether romantic relationships and difficulties between partners and their their adoption of made or families but also the clinicians themselves.
So what I think is so important. And you know, we all have different clinical styles and flares.
So you may find that You might find yourself saying, I might have done something different. That's great.
That's that's self-determination, self-regulation. And what I really want to hammer home in terms of the the juice of this very brief section of a much larger interview is how Sherry is able to hold the space in a safe way to allow for the process to unfold.
So Mike, let's let's get that quick clip. It's about 4 min.

We're gets out. That you're a safe person to have these conversations with and that you bring you create this non judgmental curious exploratory space to understand what people's experiences.
Values beliefs and wishes are around it so it makes sense that it's beginning to percolate through your different dimensions of your practice.
I also think it's reflective of the fact that you know, almost 5% of Canadians every year now are dying with made.
And so over time, that ripple effect will touch more and more and more of us that will all know someone who's thinking about me, know someone who's received made or know some or ourselves are contemplating it at different times of our lives.
So, I really, I'm really curious, Terry, and I, and I had this question in mind when we were preparing this conversation.
So you're in this unique position of having offered psychotherapeutic support to sort of everyone in the circle of made.
The clinicians who are providing it, the patients who are seeking it. The families and friends who are supporting or who are opposed to and working through that process.
So I'm curious about what you see in terms of the psychological and emotional challenges that these different party's experience in relationship to the main journey.
Based on what you've observed so far in your critical practice. So let's start with the patient.
Who's the person who wants to who's in my office is wanting to talk about made. So the conversation doesn't usually come up right away as, hey, let's talk about Made.
It's more likely to be more subtle, something like I just can't do this anymore.
I'm done. That's it. Or you know when my cat was sick we put her down.

You know, humanely why can't we do that with people? So the point I'm trying to make here is how so very difficult it is for our patients to speak directly to us.
About wanting to end their life. Like think about how The very 1st thing we talked to clients when they come in for psychotherapy or any kind of, you know, therapeutic experience like this.
We talk about our policies and we talk about confidentiality. And one of the 1st things we tell them is that if they speak about suicide or self harm, that we may no longer honor their expectation of confidentiality.
We may call 900, and, 11, have them hospitalized against their will. And many of our clients have been hospitalized against their will and it was one of the worst traumas of their life.
So for them in this circumstance to actually speak to us about end of life. Very very courageous and maybe even dangerous.
So if they do it, it is, it's huge. And even outside of the therapeutic relationship, speaking about ending one's life is against everything that society teaches.
It goes against our own inner life for survival impulses. So we're going against everything in life.

When we talk about it at all. And so our clients often come with intense shame or feelings of failure when they feel like they're giving up.
So I just want it really underline that how courageous it is for them to even speak about it at all.
And as therapists and Listeners, we just if we can keep our calm. We can be the safe place.

In all the like all the other things that we do we talk about difficult conversations that's our job And so this is just one more of those same things.
We already know how to do this. Just expanded to this. So a conversation or a request about made has a whole lot of aspects to it.
It's an appeal for help. It's an appeal for understanding. It's, it's, it's, it's, it's a begging for a relief of suffering.
It's an exercise of personal autonomy. People want control over their lives over how they'll die.
You know, and many of our clients have never had control over anything in their lives. So if this was the 1st thing they got to control, wouldn't that be wonderful?
So I invite an ongoing conversation with my clients about this.

That was cherry and Sherry's in-depth experience. So that's really just a clip of a larger interview that Dr.
Frolic had held with with Sherry. I think what really resonates for me and would love your thoughts, Andrea in terms of the overall gestalt of the interview, but really the holding the space in a in a non-stigmatizing way.
You know, one of the questions that have come up in the Q&A, are what are some of the values associated with made?
Self-determination, agency. Autonomy and you know, there is this whole concept of dying with dignity, which from a psychology perspective, respect for the dignity of persons is actually our 1st principle and pillar.
So we'd love to hear your thoughts Andrea on and your reflections.

Yeah, I think the other piece that I would underline and share this practice, which I have observed by the distance.
And she has provided. Support to both, and families that, have been referred to her, but also has provided support to members of the team who works out of Hamilton Health Sciences.
Is really this, whole person approach that she brings. So seeing the patient. Honoring their values, their wishes, but also seeing them as nested within a social world.
And thinking about how to draw in resources from that social world, whether it's family support, whether it's aspects of their own spirituality.
Whether it's aspects of their own culture that can help them in navigating what does it mean for me to make meaning of my suffering.
Now, what does it mean for me to confront my mortality and confront that in a way that is culturally and individually meaningful for me.
What does it mean for me to both assert my autonomy as an individual, but also compassionately engaged with the people around me who love me and who will as as Catherine has said, will live on with the legacy of my living and dying.
So I think, that's something that really strikes me. Is, Cheryl, never sees any of her clients, especially around the main space as just Adams in space, you know, bouncing around, but really see them as whole persons.
And works with them to amplify both the inner resources that can help them navigate the complexities of their suffering and situation, but also really works with them with their permission and collaboratively to think about how to draw in resources from their larger care ecology.
So that's another thing that really strikes me as important about the practice. Thank you, Andrea.

And, you know, we could talk about and analyze this this interview, but also the larger issues all day.
It is such an important and fascinating and complex topic, but let's perhaps for the sake of time jump into the Q&A.
There's lots of great participation in the Q&A. Folks are really leaning into this topic.

So Mike, if we can bring Catherine into the conversation as well. I want to just 1st start off there's a few themes in in the the questions around how do we, appreciate, variables like multiculturalism, multiculturalism and, you know, really client specific care, intersections of identities, but if maybe you could give this because some of this is theoretical for folks, right?
Maybe give us sense of what has it looked like because you folks have been really part of this very sacred process.
So would love to hear maybe, Katherine, if you could start and then Andrew would love for you to jump in.
Sure, thank you. It's a really great question. And so I'll. I'll sound off a couple of examples, and I'm coming from a Northern Ontario perspective where, you know, a pretty high proportion of the population is Catholic.
And so something that we have come. Up pretty often is someone might have their religious affiliation. When they come to hospital, be Roman Catholic.
And sometimes assumptions get made while this person wouldn't wouldn't be interested in made or that wouldn't align with their values and yet we have those patients who it does and that's something that's an ongoing struggle for them in terms of coming to terms with how their faith, and their goals and beliefs might not fully jive and in the right way and to them and reconciling that and also navigating
their their faith support which Some individuals will be supportive in their community and some will not. So that's 1 example.
Another example is, language, which comes along with culture. So I've I've been Unfortunately, I have been part of a conversation where relying on a translator to speak with a patient, where I wasn't confident.
Dot what I was saying in terms of navigating their major request was actually getting through. To the person.
And so something that does give me comfort is that, professional translators are held to a standard to ensure that that communication, which is a part of the safeguarding process actually happens.
And the other. I'm happy to follow up to link is that, came up has posted through William Osler, made resources that have been translated into a number of different languages.
And it's pretty extensive. So those written resources being available on the person's, 1st language can make a huge difference for the communication.
The last thing I'll say is just that, culture. Can inform somebody's perspective.

Religion can inform somebody's perspective and yet we exist as individuals who might have you know, our own conflicts.
So I think seeing the person through the identity, kind of working to balance the community supports and also that How it supports autonomy, but made also threatened autonomy and making sure the information is there.
Andrew, what do you thought? Yeah, I would add to it. That as we approach the made provision process as we approach the day of the patient's death.
We, if a patient has been found eligible through 2 assessments and has said an intention to receive made and has at a date.
For their procedure, we begin a process in collaboration with the patient and their loved ones their community called we call death choreography which is a process by which We embrace the oddity of made in the sense that it's very unusual for humans to know the day and time of their death.
And to be able to have some say about what happens to them in the days leading up. And how they orchestrate that those last hours and moments.
So we work closely with patients and their families to make, that every meaningful time for them.

Sometimes that involves, ritual and various sorts. It can involve having a community faith leader come and say prayers or conduct ritual and can involve having friends and family come and do sort of a living with the fit with the patient while they're still there and alive and sharing memories.
Sharing stories, selling photos, for example, sometimes we've had patients who have their spiritual community not in the room with them but just outside the room.
Doing pointing or prayers or other kinds of ritual. We really try to make ourselves very small in the made provision process as healthcare providers and try to allow the patient and family to take up all the space in the room, so that it can really be about their own individual experience, but also being mindful that this is an experience that touches not just the family but the whole community.
So really welcoming the people in collaboration with their community to create and help choreograph an end of life process that is meaningful both for them and for the people that they need behind.
Thank you, Andrea. Another sort of cluster of questions or themes are really around concerns about those who are most vulnerable, most marginalized, particularly when it comes to mental health and addictions types of treatments, psychological treatment.
We know that it's not universally accessible. And there are pockets of inequity there. You know, my 1st reflexions are kind of the balance, Catherine, that you're saying from group identity through to individual human being.
It's this fascinating dialectic where folks fought for the right. By actually challenging the charter and section 7 and 15 in particular around non-discrimination particularly about disability so that folks would be able to have the ability to receive made.
They eventually had won that. Sue Rodriguez's case in 1,993 was not the case but over that timeline that the experts have shown really showed that this is actually something that is seen now as part of, determined as part of a human right.
And individuals when they come and present to you are individuals and yet they are part of larger context and intersecting identities.
So on one hand we have some folks that say this absolutely should be provided because it should be a human right.
And then we have the other polarity that says, you cannot provide this, it will be absolute, just terrible, you know, all this death where, you know, for folks who are marginalized and should have received treatment and if they received treatment they would have been, you know, resolved of their suffering and managing that dialectic because we don't deal with groups.
We deal with human beings embedded in their context directly in front of us and there's risk one way or the other.

I assume there's just sense of risk or threat potentially for the clinician. So I would love maybe I'll start off with that with you Andrea.
What are your thoughts on how can we best serve folks with who have these sort of marginalized identities and how do we be mindful of both not negating their individual rights while also understanding systemic barriers and access.
I'm gonna make it really clear. Access to resources appears nowhere in the main criteria.

You cannot receive made because you lack resources, either housing or access to health care, etc.
So you have to have a grievous in your, need a medical condition and meet all of the clinical criteria that go along with that.
So I want to make it really clear that that there's no real opening for medical assistance in dying on the basis of sort of social factors they all have to be grounded in in the criminal code in those criteria.
But for those, patients who present, you know, with these complex. Factors that make us wonder about their vulnerability.
Either to have a voice or to access the resources that would actually amplify and support their quality of life.
This is where you need an interdisciplinary team. I would say never do these assessments a little.

I'm always draw in the interdisciplinary team. You're going to need the resources and expertise of the social worker of a system navigator.
Perhaps of the whole care nurse, perhaps of the shelter worker. So these, patients really call out or, attending to the whole ecology of care around them, including the patient's own support system.
And throw it's really through that multi disciplinary lens and again taking that whole person approach that the team can really begin to pull apart what aspects of this patient suffering could be remediated through more social or housing supports.
What aspects of this picture and suffering actually are not remediable because they are intrinsic to that patient sort of physical situation, disability, in your, in your, in, in, a, a, medical condition.
So I would say brought forward you, the wisdom and resources of the team, so that they can really hold the complexity of that individual case and then finally as you say, that create every individual as an individual, not as a case study, not as a stereotype, but really deeply listen, get quiet and listen.
Lean in to that patient's individual story, history, values.
Thank you, I would love to hear your thoughts on that, Katherine.

Yeah, and again, a really great question. And, you know, I think that, yeah, part of it is that in exploring the Okay.
Options available to relieve suffering from my experiences. Clients and patients who are exploring this, they want to entertain those opportunities.
Many have even We'll make that request saying. This is really a backup option. I just want the reassurance.

I'm willing to try this treatment option or this. You know, this service. But if I'm still suffering and this doesn't work out, you know, I just want to know that I have a way to relieve my suffering.
The other thing is I think about the clients or patients values and their goals. And I think that this comes up again with managing this question.
Health care providers are not going to resolve the question of structural vulnerability as individuals. And I think Andrew spoke really well to that.
And part of this is also at the level of policy and, you know, asking our governments, you know, that what resources need to be in place to consider continuing to expand the law.
But as we are now in our current state, working with the patients in front of us. Thinking about, Folk like Greg.

What if I told you that Greg inherited his farm from his dad has always lived on the farm and the idea of moving into town to have more support surfaces available to him.
Would be unacceptable for him. And so That plays a role in how individuals might navigate, different options to relieve their suffering.
So. What is the person's individual values and goals? And I think having a health care provider who has a long-standing relationship with the patient or client.
Really actually helps to make that exploration more meaningful and more nuanced as opposed to someone who's parachuting in who's had.
More limited interactions with this person. So just wanna put that out there as well. Thank you for your insights, folks.
And you know, as we wrap up here, I'll be handing over to Barry in a moment.

Just extremely grateful for the rigor and quality of the discussion we've had and for the quality of the questions that have come in.
Folks have been leaning into this topic asking some some fantastic questions many of which we can't answer today.
It sounds like there's a thirst for ongoing knowledge. One of the questions came up around how do we refer to other psych associates and psychologists?
Well, the reality is that's going to be up to the communities. The professionals and, you know, communities of practice.
At the college, of course, we're very much mindful of ensuring that we keep up to date with with advancements and treatments and with the field we're grounded by the legislation standards and codes of ethics, but in terms of how this comes along, often times it is the professionals who are out there in the space.
So it sounds like there's an interest. Historically, as a mental health provider myself, I've seen us as mental health providers avoid or use hyperbolic grandiose statements again to avoid.
It sounds like in part there's a sense of leaning in a little bit more into this ambiguity.
I think that would be good for Ontario residents because outside of the headlines, we have vulnerable folks who come to see us for compassionate and mindful care and we all need to be treated with dignity and respect.
Thank you so much, Barry. I'm gonna hand it over to you for final words.

There you are, sir. Sorry, thank you very much all of our presenters for providing us with a lot of valuable information that you a huge amount that you packed into a very, very short time.
And for giving practitioners and others tools to navigate really complex situations. And to look unflinchingly.
At the issue so that we can make more thoughtful and more supportive. Interventions and help people with and their loved ones in situations of diversity diversity of different kinds of serious pain.
So I just, I personally appreciate it and hope that I'm expressing the appreciation of the others who Watch a big, big thanks to college staff behind the scenes who most people never get to see.
Who make these events happen so smoothly in particular this time around to Odessa, as well as Stephanie Morton.

I can assure you this does not happen with a lot of hard work and skill. Thanks for taking the time out to all of you from your busy schedules to join us.
And I just want to encourage you all to fill out the evaluation surveys. That would be a arriving in your inboxes very soon if they haven't already.
We take the time to read them all. And use the information to help guide us in planning future events.
So thank you all very, very much.