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Oral medical assistance in dying (MAiD): informing practice to enhance utilization in Canada

  • Christopher Harty
  • Alan J. Chaput
  • Konia Trouton
  • Donna Buna
  • Viren N. NaikEmail author
Special Article

Abstract

The legislation Bill C-14 legalized medical assistance in dying (MAiD) in Canada. After thorough assessments of eligibility by two clinicians, Bill C-14 allows for both intravenous-assisted death by a clinician (euthanasia) and prescription of oral medication for self-administration (assisted suicide). Nevertheless, since inception in June 2016, intravenous euthanasia is the main form of delivery of assisted death in Canada. The reasons why oral MAiD is underutilized in Canada are multifactorial. Currently, there is no consensus on either the medications or the protocols for oral administration, nor a comprehensive understanding of the potential side effects and complications associated with different regimens. The quality of evidence for optimal MAiD medications is low, so any suggested recommendations can only be informed by the global but generally anecdotal experience. The challenges for implementing oral MAiD in Canada include a need to enhance clinician comfort in prescribing oral medications as an alternative to intravenous administration. The goals for ideal oral MAiD medications are 100% effectiveness and minimal side effects, while ensuring that the needed dose is both palatable and deliverable in a tolerable oral volume. The Netherlands has the most experience worldwide and barbiturates have emerged as the most common, efficacious, and tolerable agents by patients. Based on this global experience and the over-arching goals for oral MAiD, we recommend the use of a secobarbital suspension combined with antiemetic prophylaxis.

L’aide médicale à mourir administrée par voie orale : comment éclairer la pratique pour en améliorer son utilisation au Canada

Résumé

Le projet de loi C-14 a légalisé l’aide médicale à mourir au Canada. Après une évaluation exhaustive de l’éligibilité par deux cliniciens, le projet de loi C-14 permet d’offrir une aide médicale à mourir administrée par un clinicien par voie intraveineuse (l’euthanasie) aussi bien qu’une aide médicale à mourir auto-administrée, soit la prescription de médicaments oraux pour auto-administration (le suicide médicalement assisté ou suicide assisté). Toutefois, depuis sa mise en œuvre en juin 2016, l’euthanasie par voie intraveineuse est la forme prépondérante d’aide médicale à mourir utilisée au Canada. Les raisons pour expliquer cette sous-utilisation de l’aide médicale à mourir auto-administrée au Canada sont nombreuses et multifactorielles. À l’heure actuelle, il n’existe pas de consensus quant aux médicaments ou aux protocoles d’administration orale, ni une compréhension exhaustive des effets secondaires potentiels et des complications associées à différentes posologies. La qualité des données probantes concernant la médication optimale pour une aide médicale à mourir auto-administrée est faible, donc toute recommandation proposée n’est basée que sur une expérience globale mais de nature généralement anecdotique. Les défis de la mise en œuvre de l’aide médicale à mourir administrée par voie orale au Canada comprennent la nécessité de rendre le clinicien plus à l’aise avec la prescription de médicaments oraux comme alternative à une administration intraveineuse. Les objectifs d’une médication idéale pour l’aide médicale à mourir auto-administrée sont son efficacité totale avec des effets secondaires minimaux, tout en garantissant que la dose nécessaire ne soit pas désagréable au goût et puisse être prise dans un volume oral tolérable. Les Pays-Bas sont le pays ayant l’expérience la plus complète et les barbituriques y sont devenus les agents les plus répandus, efficaces et tolérables pour les patients. Sur la base de cette expérience mondiale et des objectifs globaux de l’aide médicale à mourir administrée par voie orale, nous recommandons d’utiliser une suspension de sécobarbitale combinée à une prophylaxie antiémétique.

Notes

Conflict of interest

None declared.

Editorial responsibility

This submission was handled by Dr. Hilary P. Grocott, Editor-in-Chief, Canadian Journal of Anesthesia.

Author contributions

All authors contributed to all aspects of this manuscript, including study conception and design; acquisition, analysis, and interpretation of data; and drafting the article.

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Copyright information

© Canadian Anesthesiologists' Society 2019

Authors and Affiliations

  • Christopher Harty
    • 1
  • Alan J. Chaput
    • 1
  • Konia Trouton
    • 2
  • Donna Buna
    • 2
  • Viren N. Naik
    • 1
    Email author
  1. 1.Department of Anesthesiology and Pain Medicine, Faculty of MedicineUniversity of OttawaOttawaCanada
  2. 2.University of British ColumbiaVancouverCanada

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