 All right, why don't we go ahead and start? Again, thank you everyone for tuning in this afternoon or this morning or whatever time it may be where you're at. My name is Bob Trug. I'm the director of the Center for Bioethics at Harvard Medical School. And this is a part of our series on contemporary books in bioethics. And today we are really excited to have Dr. Stephanie Green discussing her recent book, This Is Assisted Dying. Let me give you a little bit of background on her from her bio. After obtaining her medical degree at McGillnate University in 1993, Dr. Stephanie Green completed a residency in family medicine and then fellowships in palliative care and infant and maternal health. After more than 20 years in practice and in conjunction with a change in federal law in Canada, Dr. Green began working in medical assistance in dying or what we call made in June of 2016. She is co-founder and president of the Canadian Association of Made Assessors and Providers. Not sure how you pronounce the acronym. Cam app. Cam app, cam app. Okay, thank you. You got it. Cam app, cam app. Medical advisor to the British Columbia Ministry of Health and made oversight committee, moderator of cam apps, national online community of practice and as hosted three national conferences on the topic. The book, This Is Assisted Dying is a memoir of her first year providing assisted dying in Canada and it is her first book. Just a word of logistics here. As I'm sure almost all of you are familiar, you've got two functions down there at the bottom, the chat box and the Q&A. We're gonna be using the Q&A box exclusively in terms of what we'll be monitoring and looking at. So you can put things in the chat box, but there's no guarantee that any of us will see them. But please do put your questions in the Q&A. I'll be keeping an eye on that and we'll have a few minutes at the end to get to those. But for now, why don't we go ahead and get started and Dr. Green, thank you for joining us. Thanks for that. I'll just take a moment to set this up properly. Great, you're seeing my slides, I hope. Yes, we are. Great. Thanks. Good afternoon, everybody. And thanks for that introduction, Bob. It's a real pleasure to be here with you today. I've taken this opportunity, of course, to display the cover of my new book. Unlike today's slightly more academic presentation, this book is a narrative memoir. It's more of a personal journey through my first year of providing assisted dying and it explains what it is and how it works and how it feels as a physician to administer the drugs that will end a person's life. I'd like to suggest that it's a worthy companion to today's talk. But today I actually want to give you a different type of overview. I want to speak to you more as colleagues and peers, as medical students, professors and interested guests. So what qualifies me to give this talk? Well, as you've just heard, I spent 20 years in maternity and newborn care before I changed my focus to assisted dying in 2016. And oddly, because 90% of my clinical work now is based around this care, I have become one of the more experienced providers of Maid in Canada. I flag two potential conflicts with today's talk just to mention briefly. And while I'm tremendously proud to say that I'm the co-founder and president of the Canadian Association of Maid Assessors and Providers, that is CAMAC, please note that nothing I say today is on behalf of that organization, should be taken as a reflection of that organization and all thoughts and comments, of course, are strictly my own. And of course, I have recently published a book and while I'd like to think that it would be insightful and of interest for you, you certainly don't need to buy it or read it. So in the next short hour, in about 30 to 40 minutes, I'm gonna just, in very broad strokes, I wanna first define what it is that I'm gonna be talking about and I'm gonna contextualize it so we can understand why we're talking about assisted dying and how it might be relevant to your world in Boston in 2022. I'm briefly gonna share some data. I'm gonna highlight some practical implications of the work. I'm gonna touch on the role that clinicians have played in the evolution of assisted dying in Canada and I'm gonna end with a few lessons that I think are relevant to anyone in a jurisdiction that's considering assisted dying legislation and of course make sure to leave time for questions and answers at the end, which I think can be the most interesting time. This is not, of course, a scoping review of the topic, it simply can't be, I would need more time for that, but I do hope it's relevant to the audience today. I hope it's informative and maybe challenging and if we can dispel some myths and misinformation, that would be all the better. So what exactly am I talking about? Well, depending on what you read and who wrote it, maybe who published it or what year that happened, you might come across quite a bit of different or even confusing terminology. So that may be very clear from the beginning what I mean by my terms. So assisted suicide or physician assisted suicide, these are terms that are still used quite often in the United States. They're meant to describe the situation when lethal medications are prescribed by a healthcare practitioner, but that they're self-administered by the patient and often without the clinician being present. So it's usually a drink, usually a mixture of foul-tasting barbiturates to be precise and the person usually holds it and needs to drink it themselves. So the modern understanding of the term euthanasia by contrast is defined as the administration of the lethal medication by the healthcare professional. So it's always at the explicit request of a competent adult and it's with the goal of relieving further pain and suffering. So it's also the preferred term that's used for assisted dying in Europe today. So the key difference between assisted suicide in euthanasia simply is who administers the medication, the patient or the healthcare professional. Now Canada consciously chose to use a different term that of medical assistance in dying or made. So we don't talk about assisted suicide or euthanasia in Canada. In part, that's to avoid negative connotation. So outdated phrasing, such as someone committed suicide implies that maybe a crime was involved or it could. And opponents sometimes invoke the term euthanasia in order to specifically conflate assisted dying with the repugnant history of Nazi use of the word during World War II when it was used euphemistically for the killing campaigns. So not only does the term made avoid these associations, but it's also designed to be an umbrella term because in Canada, we have both self-administered and clinician-administered assisted dying. So Canada is one of only four jurisdictions in the world where that is possible, where both of these options are legally available and the Netherlands, Belgium and Luxembourg, of course, are the other three. So no one ever talks about Luxembourg. And everywhere else you might hear about assisted dying in film or in books or in lectures, everywhere like Switzerland or Australia and in some United States, these only allow a self-administered form of care. So for greatest clarity, I'm just going to simply use the term assisted dying to refer to any and all forms of this compassionate healthcare that I'm talking about today, although I will probably lapse into using the term made because I'm so accustomed to it in my own work. So that said, I do wanna just point out that when I began working in assisted dying in 2016, there were five American states that already allowed some form of this care and six countries outside of the US that allowed some form of made. So six years ago, you could say there were 11 jurisdictions globally offering some access to assisted dying to basically about 180 million people. Now, today, there are 25 jurisdictions that allow some form of this care and they include 11 regions in the US alone, as well as the entire country of Canada, of course, and it grants access to over 475 million people worldwide. So it's more than doubled. In fact, just since 2019, assisted dying has been newly legislated, implemented or offered in three United States, in New Jersey, in Maine, and in New Mexico, most of Australia, all of New Zealand, Spain, Austria, and is currently being debated in the House of Lords in England, in the Irish legislature, in the courts of Italy and Portugal, and in a complex mix of professional and legal environments in Germany, just to name the most active. As for a detailed overview of the current situation in the US, I cannot and will not cover that today in any great detail, but I do think that this map might be helpful to visualize the current landscape in the US, where the green-colored states demonstrate where assisted dying is already legalized and the year in which that became true. The light kind of salmon-colored highlights are the states that are considering legislative change, including Massachusetts, and the birch-orange-colored states are regions where there's no current intent or interest in doing so. And I'll just thank Death with Dignity, a national advocacy organization for the basis for this map, and Mara Bookbinder, a medical anthropologist down at UNC Chapel Hill for her work to update and add to the map, and of course, her permission to share it with you today. So as for the various variabilities among the state laws with respect to eligibility or procedural safeguards that are in place, I'm gonna just refer you to this article by Thaddeus Pope. Please note, though, that changes continue to happen at a pretty rapid pace, and therefore this article from 2020 is already slightly out of date. But by way of example, even less than two weeks ago, you may know that an important court challenge over residency requirements reached settlement in the states. So until now, you had to prove residency in the state before you could be found eligible for an assisted death. And that residency requirement was recently challenged in the state of Oregon, and less than two weeks ago, it's no longer required. So this is likely gonna spur similar challenges in other states with similar residency requirements, and there may be more changes coming. And of course, I would be remiss if I didn't recognize that the topic of assisted dying might be of special relevance to today's audience. Of course, as Massachusetts highest court is hearing the appeal of Dr. Roger Klegler, a physician and a patient who's asking the courts to allow physicians to prescribe lethal medications for terminally ill patients who want to end their lives. I understand that the state's attorney general is arguing that doctors who prescribe such medications could actually be prosecuted for manslaughter, and that in her opinion, the issue is one for lawmakers and not the courts to address. But lawyers for Klegler, of course, argue that the court shouldn't act because the lawmakers haven't. And I suspect you're also familiar with the fact that voters narrowly rejected a 2012 end of life ballot question in Massachusetts, and that multiple end of life bills have not progressed through the state legislature, but that recently a new end of life act was introduced in 2021. And there's actually a suggestion that there's gonna be a potential vote on the matter in 2022 in your region. I also actually understand that just last week, your state's attorney general was quoted as saying she's now open to working with the medical community and with patient advocacy groups to consider changes in the law. So it sounds like things are moving in Massachusetts. So that said, in that context in place, I do wanna take a few moments to just describe some basics of the assisted dine model that I work in in Canada. I think it'll inform the rest of our discussion later on and probably help with the Q and As. So bear with me as I take a few minutes to explain how this came to be and how assisted dine works in the Canadian model because I do believe it is somewhat unique. So in an effort not to get too deep into the Canadian weeds, suffice it to say, because I could get very deep in those weeds. I suffice to say that in 2011, two women and their families challenged the blanket prohibition of assisted dine that previously existed in all of Canada. So the big black box, if you will, and you'll please excuse my very basic graphics. So Kate Carter, it needs to be noted was an 89-year-old woman suffering from spinal stenosis. So a progressive, painful, non-terminal condition that caused her intolerable suffering. So she ultimately chose to go to Switzerland and receive an assisted death in 2010. And Gloria Taylor was suffering from ALS, it's a cruel and as you know, a relentlessly progressive neurologic condition which would of course ultimately be disabling and fatal. So appealing to the Canadian Charter of Rights and Freedoms, the Carter lawsuit argued that the prohibition of assisted dying violated certain patients' equality provisions and their rights to life, liberty and security of persons. Patients like Carter and Taylor who were what was termed grievously and irremediably ill. So basically very sick and incurably so. Interesting, there we go. Now I am not a legal scholar and I will not go into the really interesting legal arguments that I've come to understand. But Justice Lynn Smith, a constitutional expert I'm told, wrote the original trial decision and she agreed. She also considered a tremendous amount of evidence and she concluded that A, clinicians are indeed capable of assessing people for the uncoerced capacity that's required to make requests like this, meaning clinicians know how to do their jobs. And that B, that data does exist that shows rigorous models of care that can be implemented or that there were in fact international models and evidence of such examples and that they appear to balance the respect for individual autonomy while also reasonably safeguarding the most vulnerable in society. So it was an important decision. And the original trial victory was overturned on appeal but eventually it was unanimously upheld by the Supreme Court of Canada. So practically speaking, the court had carved out this blue square from within the black box, the circumstances under which the provision of an assisted death would no longer be criminal. And that was when it was requested by a capable adult who was suffering intolerably from a grievous and irremediable condition. You will please note that Canadian law did not change because voters demanded it or because government felt like it was a good idea but because patients demanded it based on their constitutional rights. And that was a unique basis for assisted dying globally at that time. So our whole model of care then is rights-based and completely patient-centered. You might also note that nowhere in this decision is there a requirement that the person be terminally ill or even near end of life. So that invalidity of the criminal code provisions, that was suspended to allow the government time to act. And then in 2016, 16 months later, the federal government enacted legislation that was however more restrictive than the conditions outlined in the original court's decision. So it's represented by the smaller green pentagon. So specifically, while the courts didn't require a person to have a terminal illness, the new government legislation required a person to have what was termed a reasonably foreseeable natural death, a term that nobody understood. But eventually we did come to understand that it meant that death was reasonably predictable really in kind of medical speak and that it had no specific timeframe imposed around that however. So that could mean it was temporarily related to death. There's a temporal proximity to death that someone might be dying soon, that death was coming soon, say a person with stage four pancreatic cancer or that death might be predictable because of the person's combination of known medical condition and the potential sequelae. So maybe a diagnosis of ALS or significant heart disease or significant lung disease. So again, no timeframe around that but just on a trajectory to work that predictable path. The story didn't end there. I'm gonna skip a whole bunch of twists and turns and just say that this particular more restrictive element this law requiring a reasonably foreseeable natural death was challenged and eventually, but not surprisingly also found to be invalid. And in 2021, so very recently, just a year ago really Canadian legislation was amended so that that requirement of a reasonably foreseeable death was removed and it took the federal legislation a significant step closer to the original Supreme Court decision which we refer to this change as C7, it was the bill. This is important to understand because sometimes opponents will talk about slippery slopes and suggest that Canadian law has been expanding rapidly since it began. But the truth is we had a court decision that was much more open. We had initial legislation that was much more restrictive and we now have something in between. So without all in mind and for reference as much as anything else, I just wanna demonstrate that we're not so grossly different than most jurisdictions. I'm gonna tell you that current Canadian law now states that to be eligible for an assisted death you need to be A, an adult over 18 years of age. You need to be eligible for Canadian government funded healthcare services. So you don't have to be a citizen but you need to be eligible for our healthcare. So essentially tourists can't come to Canada and pay privately for this. That is not legal and I don't expect that we'll ever change. Patient needs to make a voluntary request for this care. They can't be coerced into this by any other person or something internally or externally has to be an uncoerced voluntary request. Patient needs to have capacity to make the request for made and give informed consent. Essentially they need to understand their illness. They need to understand their treatment options and the pros and cons of them and the possibility of palliative care and what they can offer them. They need to understand and appreciate the ramifications of their decision for themselves and their loved ones and to articulate that request. So that's all involved in the capacity and the giving of informed consent. And of course they need to have what we've called the grievous and irremediable condition. And that is currently defined actually in the criminal code of our country. You can see this is quite rigorous. Currently the definition of a grievous and irremediable condition implies that the patient has a serious and incurable illness that has put them in an advanced state of irreversible decline and function essentially and that they're enduring a suffering that is intolerable to them and cannot be relieved by any means acceptable to them. So I know I went through that very quickly. A little asterisk is there for me to remember to tell you that with our current legislation if a mental health disorder is your sole underlying reason for applying for made you are currently excluded from accessing this care but that exclusion will automatically sunset out of our law, out of our legislation in March of 2023 and that will actually become available. So that's the quick run through of a lot of material. So if you meet all the eligibility criteria you can potentially have an assisted death in Canada but how you get there depends and I promise I won't go through all of this for you just to say that there are also a number of procedural safeguards that are required and our newly amended law created two tracks or two pathways to assisted dying. What determines which track you're on? One track is a little bit more straightforward than the other. What determines what track you're on is whether your death is reasonably foreseeable. So very unfortunately the government kind of recalled decided to use a recently discarded terminology. So track one, if your death is reasonably foreseeable there's a straightforward number of safeguards like you have to make a written request that need to be a witnessed written request you need to see two different clinicians pretty straightforward. If your death is not reasonably foreseeable you would follow track two you need to have all the same safeguards as track one plus there are more of them which makes sense of course because these are people who aren't on a trajectory towards death so deserve a more rigorous assessment and more rigorous safeguards. So knowing all of this, what is actually happening? What kind of data are we seeing in the Canadian model of care? So all this information comes from the second annual report on medical assistance and dying from 2020 all this data is from 2019. So just very briefly we are seeing a steady annual increase in assisted deaths in Canada. I would add that this is not surprising nor should it be alarming. It's still relatively new. People are still not yet fully aware of its existence which is surprising to me because I live in a made bubble of course and as the idea penetrates into the public sphere and we've seen Canadians embrace this type of medical care it is not surprising to see this kind of access really growing. It's essentially a new end of life option available to Canadians but better yet to maybe contextualize it. So in Canada in 2019, 2.5% of all annual deaths were attributable to assisted dying. You can see the range between our different provinces there is the variation amongst us but the Canadian average is 2.5%. Now comparing that to Oregon next to that it's a region with 20 years of experience but where access is limited to those with terminal illness and those who have to self-administer so not surprisingly the rates are lower and in fact they are significantly under 1%. But comparing that to the Netherlands where the model of care is much more similar to the Canadian model, terminal illness is not required clinicians can administer care. A lot of our model is based on the Dutch model and there consistently the percentage of annual deaths attributable to assisted dying is consistently between four and 4.5% depending on the year you look at. So after only three years of legalization for Canada to be sitting at 2.5% seems exactly as might be expected. Very quickly then in Canada we're seeing both male and females accessing care in almost equal numbers. The age range of those receiving assisted deaths is quite wide, the highest prevalence is between 55 and 80 with the average age being 75. You can see the oldest the youngest recorded. I personally the youngest person I've ever assisted was 27 with a terribly metastatic breast cancer and the oldest person I have personally helped was 105 with heart disease. And regarding underlying diagnoses by far the most common underlying illness leading to an assisted death is cancer that's consistent with other jurisdictions. We see neurologic conditions and end stage organ failure and stage heart disease and stage lung disease and stage liver disease in almost equal measure after that. As for where it's happening there are some centers in Canada large centers where hospital-based programs tend to be the more robust programs and there are other centers where home-based programs seem to be more robust. But overall, if you look at the whole Canadian data it's almost equal between home and hospital but as I like to say made can be provided anywhere that's safe and legal. I personally have provided made in hospitals in people's homes which is by far the most common what I do but in palliative care settings and seniors residences and assisted living facilities. I've helped people in hotel rooms in backyards on patios on beach. I have a colleague who's helped someone in a funeral home that's kind of new and I am aware of one that actually happened in the camper van. So we have lots of diverse locations for sure but primarily home and hospital. So I've explained all of this to you in order to highlight some of the few important differences between the Canadian system and some of the US states and to look at some of their practical applications. So first and foremost as I keep saying in Canada it's not required that a patient have a terminal illness to qualify for an assisted death. Now, this is actually not so odd or shocking as it may seem at first. So the Dutch for example, they emphasize the eligibility requirement of unbearable suffering in their list of mandatory criteria. And the Belgians focus on the presence of what they call medically hopeless situation. The Swiss, the only jurisdiction that allows foreigners to access this type of care requires only that the medication be self-administered and that there be no selfish motivation in the one who's actually doing the assisting. So none of these assisted dying programs is designed to be used exclusively at end of life. And as in Canada, they are instead focused on autonomy, on patient suffering and on irremediability as the key factors in determining eligibility. Of course in the US the very first state to enact legislation was Oregon in 1997 with the death dignity act which did require terminal illness defined as an expected death within six months and as an eligibility requirement, excuse me, and as other states decided to mimic that legislative success almost all the other US jurisdictions require this. And in fact, the Oregon model has been the blueprint for other legislative successes in Australia, New Zealand, probably in Spain, all of which also require terminal illness to be present. And this may make some sense in theory but I can report to you from the front lines. And we all know that clinicians are terrible at prognosticating and we all know that suffering can occur without being within six months of end of life. So when I'm in a middle-aged woman suffering from something like multi-systems atrophy or super nuclear palsy or severe heart disease or severe lung disease or even full men in Parkinson's disease, I am grateful that it doesn't matter if I cannot guess exactly how much longer she might survive with her condition. Our law allows the person themselves to decide when they have reached the point of intolerable suffering and to ask for an assisted death at that point as long as they meet all the other eligibility criteria. Secondly, as I've pointed out, clinician administration of medication is permitted in Canada. And you might be interested to know that in any and every jurisdiction where clinician administrative made is allowed, it is greatly favored by the patients. And in fact, in Canada, we've recorded over 20,000 assisted deaths in the past five or six years. And there have been less than 20 that have been self-administered. So 99.999% of ours are clinician-administered. And that's consistent with data from the Netherlands where approximately 96% of all assisted deaths are in fact, clinician-administered as well. So why is that? Well, in a self-administered assisted death, a person usually needs to be able to sit up to hold the glass, to be able to swallow, to digest. And these are things that are often no longer possible at end of life. So quite clearly this discriminates against those who are paralyzed, those who can't swallow, or those with maybe pathology in their GI tract. I mean, what about the gentleman with end stage esophageal cancer, for example? What can be done? And if the clinician isn't present, well, I'll just say that some complications have certainly been reported. Now to be fair, some creative thinking has occurred around this issue in the US. And in California, for example, the word in the legislation is ingest. A person must ingest the medication. So this has been taken to mean that any use of the GI tract is allowable. And that interpretation has led to the permissible use of feeding tubes right into the stomach, or even rectal tubes. But it still needs to be achieved by the patients themselves. So what do you do if your ALS patient can no longer swallow or push a plunger? So right now in California, the current requirement of self-administration is actually being challenged. And arguing that it is in fact discriminatory, and especially against those that are physically disabled. So I've been highlighting some differences, but there's also in fact, something that all jurisdictions seem to have in common. And that's the reasons why people ask for help. So in every case of assisted dying in Canada, it has to be reported and monitored by federal agency, by Health Canada. They generate an annual report, which provides much of the data that I'm presenting you today. And practitioners are actually required to report on how the person who's requesting made describes their own suffering. So we actually have to write that down and report that federally. So the most commonly cited descriptions that patients tell us of their suffering is that they are suffering from the loss of ability to engage in meaningful activities. And that's followed very closely by the loss of ability to perform their activities of daily living. In the state of Oregon, there's also of course annual reports and in it the most common end of life concerns, as they're called, are expressed by the patients who are requesting an assisted death. They're very, very similar. Again, a decreasing ability to participate in activities that make life enjoyable or meaningful is the number one answer. Excuse me, and the loss of autonomy is the second. So very similar. Okay, one other element I do wanna discuss very briefly is the level of involvement of clinicians in this work and its evolution, especially in Canada, but in general. So as uncertain, many of you are aware, the American Medical Association has a stated policy opposing assisted dying, although the report of their own counsel, judicial and ethical affairs outlines both positions, both for and against a physician participation. The Canadian Medical Association, by contrast, the CMA, has been statedly neutral on the topic since 2015, since right before the Carter decision. And it was done in an almost impossible effort to try to advocate on behalf of all of the CMA membership, which is about 90,000 physicians who of course hold divergent views on the subject. But it does, this statedly neutral stance does allow the CMA to more fully and purposefully participate in the ongoing public debate around the topic and to liaise and relate and consult with government, for example. So there's an important difference in the role of our National Medical Associations, I think. That said, let me be clear, our federal legislation explicitly recognizes, allows and respects conscientious objection to the practice. No clinician has ever been forced to provide this care or ever could be. It's true, however, that our professional licensing bodies do require some form of non-abandonment of the patients who are making this choice. Essentially, you can't fire a patient over their decision to seek this care and you have to still care for them in all other respects. So in fact, professional standards require an effective referral of care to alternative resources for the patient to help them address their request. So there's professional standards that are in place. Interestingly, however, there's no similar respect for what I call conscientious participation. The term I more recently learned and I quite like for when a clinician feels compelled to be available to offer this care to eligible patients. So we do have some situations where clinicians want to offer this care to qualified eligible patients but that they're affiliated, the patients are affiliated with facilities that forbid them to do so. So primarily these are faith-based institutions. So we see doctors and nurses within those facilities that may not be able to answer questions that patients pose to them about this care while they're inside that facility, for example. And it's led to a number of odd situations. So for example, I've done assessments for made outside those facilities in cafes, on park benches, in odd places. But the most important way that I think that clinicians have been involved assisted dying in Canada has been, you know, through the Canadian Association of Made Assessors and Providers. You have to remember when our law changed, when it did so, assisted dying sort of became suddenly legal or suddenly non-criminal. And there was no training. There was no guidance documents. There were no medical standards. It was very little help. It was left to clinicians to kind of do the work to sort out what it meant to determine if the law was met and how to apply the mandated safeguards. So some clinicians therefore stepped in to help set those standards and to create that training and to learn from each other and to learn from those who had gone before us and other jurisdiction. And from that very small group, few clinicians who were willing to take on the work in the very earliest of days came this organization. And this organization's mission, of course, is to support those who do the work of assisted dying. And let's be clear, there was no other professional association that could do that because we came from such a wide variety of backgrounds. We are primarily family physicians, nursing nurse practitioners, internists, neurologists, anesthesiologists, psychiatrists. So we needed a new association that could represent us in our new field of work. A lot of what we do is we educate about made, about what it is about what it isn't, especially do so to the healthcare community. And we are hopefully a leading voice trying to become a leader in the setting of the highest of medical standards for this new field of care. This is all achieved through things like an established and active community of practice online, but there's daily interactions between colleagues across the country. We run training workshops for clinicians who are interested in doing the work or coming to the work. We've developed clinical guidance documents, national case sharing webinars, educational conferences, all kinds of projects, but fairly unique organization in its founding. I like to think we were able to inspire others elsewhere, including a very similar American group which now exists called the American Clinicians Academy on Medical Aden Dine, and I urge you to check them out if you're remotely interested. So in my last few minutes, I do wanna highlight just three or four lessons that have been learned and then turn this over to an open Q&A. So very briefly, as might be obvious by now, I work in a system that did not allow for much preparation. If you want to learn what it was like to try to understand what to do, how to function in a brand new system without formal training, how to take more than a few big blind steps, potentially criminally liable steps at that, my book candidly tells the story of my first year providing this care, and I do hope you find it illuminating and insightful. But the Australians, for example, were wise and learned from us and others, and they first passed legislation in the state of Victoria, and then they mandated an 18 month preparation time. If you ever find yourselves in a state with pending new legislation on assisted dying, I urge sufficient preparation for the clinicians who are interested in participating. Some people argue that patients only ask for assisted dying due to lack of access to quality palliative care. I'd point out that the data does not support this. Data from Canada's 2020 report states that of all the patients who received made in Canada in 2019, 83% of them were already receiving palliative care at the time of their death, and of those who were not receiving palliative care, another 17%. 88% of them did have access palliative care services if they had one of them. So I routinely provide made to patients already receiving outstanding palliative care on palliative care wards, people being supported by palliative care at home, in hospice units, so routinely. So my experience assisted dying is not due to a failure of palliative care, nor is it due to access issues where I live. Of course, we can always do better on a strong supporter of increased funding for palliative care, for greater access to palliative care. I also recognize that I live in a center in a region that's fortunate enough to have good access to high quality palliative care, not everybody does. So there is that, but the data is fairly clear. Next, I do wanna share with you that when I tell someone that they're eligible for an assisted death, almost every time, I see an immediate physical change in them, right? A relaxing of the shoulder, sometimes a little smirk, almost always an expression of relief and gratitude for the near possibility. Some find this confirmation of eligibility, it reduces their suffering enough that they actually choose to live a little longer. And you might know the data from Oregon that suggests only 65% of those were given a prescription for an assisted death in Oregon, actually ever use it. So I found that allowing for the option is actually empowering to the patient and therapeutic in and of itself. And finally, yes, it's not all sunshine and roses. I have encountered angry families, people who disagree with what's going on. I do always try to facilitate discussions between the different parties. I try very much to encourage the patient to be the one to explain what they're asking for and why, if they're able to do so. I think it's important that everyone be heard in a respectful manner, that solutions and closure are very much worth seeking. And that can either be done with my facilitation or with professional counselors, of course. But in the end, do know the law and I do take my cues from the patient. Family and loved ones deserve to be heard but they have no legal standing where I work. I won't be bullied and I won't allow my patients to be bullied. We do hear opponents who often talk about coercion and a fear of having people coerced into making this decision to end their lives. That's not something I have actually really ever seen. It was one case I was concerned about. They did not proceed in all my years. But I have seen more than a handful of cases where patients were seemingly coerced out of making this choice or where they felt that they would be letting their families down or letting a loved one down or disappointing somebody if they did proceed despite their own clear desire to do so. If I have a parting message for you, it would be that somewhat to my surprise maybe or to the surprise of others, I don't find this work more gross or morbid or untenable as a physician. I consider it a physician's role to help people. I think that's why we all went into medical school why we went into medicine. And sure, sometimes we can diagnose issues and sometimes we can even treat them or cure them. But I don't think that's the majority of our work. Certainly as a family physician, I don't really think so. People have come to see me during some of the most challenging times in their lives. And sometimes I can treat them and sometimes I can help them, but not always. So the expression goes, right? Sometimes to treat sometimes, to care often but to comfort always, right? I found my work in assisted dying to not be so different than my role as a physician in any other part of my career. And in general, I find that to be invited into that intimate time with patients and their families to help them facilitate what are essentially their final wishes. I have found that to be profoundly meaningful work to be honest. So I've only scratched the surface on the topic today but according to the pigeons here, it's at least a way to avoid misunderstanding or misinterpretation. So I certainly welcome your questions. Stephanie, thank you so much for that really concise talk that covered so much territory. And I've been taking notes out of the Q&A and I'm gonna try to synthesize some of the questions. Maybe one though is that I know that your book, as you said, is more of a memoir. And at the very end, you spoke a little bit about your personal experiences, but some of the comments are, what has it been like for you personally to be involved in this? What, yeah, what has that been like? Yeah, I think, yeah, I appreciate the question actually. So having spent 20 years in maternity care and adoring my practice, I spent much of my time feeling quite grateful to be able to be invited into that sacred space, into that space with families who are having this tremendous change, that tremendous transition. And I find a lot of similarities with end of life actually. I find that in both of those situations, there's a lot of intensity, there's a lot of emotion involved, there's a lot of family dynamics involved. There's a lot of my, my role is supposed to be guiding and be knowledgeable, helping people through these challenging times, but it's extremely obvious to me in both of these situations, and especially at end of life, that I am not the most important person in that room, right? You know, it's my job to guide the situation to some extent, but there's a lot of paradox in this work. But there's a lot of, there's to be sadness, there can be tragedy sometimes, someone's life is ending, but at the same time, I have been witness to some extraordinary moments of beauty, of people saying goodbye to each other, of finding closure with each other, of finding peace at the end of their life, of having this opportunity to take the time to finalize and say goodbye and tell the people they love. I kind of witnessed this journey with patients. I find it really extraordinary work and I found it very, very meaningful. And patients have been incredibly grateful for this care. I've been a little bit overwhelmed by that, to be honest. You mentioned that terminal illness is not a requirement. And forgive me if I miss this and taking notes, but many people are just concerned about psychiatric disease in general. And a lot of debate here around physician aid and dying, for example, with patients with eating disorders. And when do you decide that something is no longer treatable? It seems to be such an area of uncertainty. How do you manage that? Well, it's a very pertinent question to us. We're about to be grappling with that very, very practically here. So just to be clear, in the original legislation in Canada, there was no particular exclusion of mental health patients from accessing made, but there was a requirement that their death be reasonably foreseeable. So essentially 99% of mental health patients couldn't access made because of that requirement. There was actually an exception for a patient with anorexia who did qualify and proceed. With our change in law, when we remove that requirement, that kind of end of life requirement, that reasonably foreseeable requirement, the government recognized that that would then open the door for mental health patients to then have access without that kind of stop gap. And that's why they inserted the blanket exclusion of those patients before they could really sink their teeth into how to do this. I mean, that exclusion means to be lifted. The Senate enforced that it needed to be coming out because of constitutional rights. You couldn't discriminate against a patient simply because of their diagnosis. That wasn't going to be allowed to happen. The courts weren't going to allow that. And the government recognized this is a complex topic. And so we have a national advisory committee that's actually about to report, I think within the next month, on this very topic and give recommendations on how we can more accurately, more carefully assess patients with mental health disorders to decide whether their illness is irremediable or not in this big debate within the community, but whether that's even possible or not, whether that's even true or not ever and how we can maybe apply some more safeguards. In March of 2023, this will be on my doorstep, at my door. These patients will be in my office. So I am very much looking forward to those recommendations and talking about this a lot further. I don't have those answers for you yet. Questions about dementia and advanced directives. Can people request made via an advanced directive? And if not, and they become demented and then they're not able to consent. You can see the issues there. And three sentences or less. So that is the question I'm asked the most in every single talk that I give. And it could be an entire lecture into itself, but I think I would just tell you the basis are like this. In our original law, it was clear that if you met all the eligibility criteria, you could have an assisted death. And at first, we weren't clear what that meant with dementia patients, did they need to have physical ailments, but it became clear that a purely cognitive decline could actually meet the criteria. I have personally assessed and helped people with dementia apply for and access medical assistance and dying. These are complex patients, not all of them do. There's a model of care that we use that allows us to follow these patients closely over a long period of time. And we call it the 10 minute to midnight. If people lose capacity to make this decision, they can't, of course, access made, but they also need to be an advanced state of decline. There are some patients that would be called 10 minutes to midnight, right before they're about to lose capacity, right before that happens. They can, if the stars align, they can actually meet all the criteria. So dementia patients can access made in Canada as long as they can give consent or on the day of. Now, can there be an advanced request where a patient says, I've got Alzheimer's, when A, B, and C are true, I would like you to end my life? That's an advanced request. We do not have that in Canada. That is not currently legal. That is the topic that most Canadians want to be discussing, have asked to make legal, that we have not yet sunk our teeth into. I think primarily because we are currently mired in the mental health debate, which has been thrust upon us by the current law, we're going to have to deal with that first. Canadians really want to be dealing with advanced requests. We do have, just to say, we do have a new loophole where some patients can give consent in advance of losing capacity. It's a very special subset of patients and some dementia patients can fit into that. But the overall comment is, dementia patients can access made sometimes in Canada, but not through an advanced request. Thank you, it is a complicated topic. Rather straightforward question, what about life insurance? Yeah, great question. We got asked that a lot. Life insurance is not affected by the all beneficiaries are paid out. The National Life Insurance folks have a statement on that. All the insurance companies have policies and assisted dying. In six years, I've never seen anybody have a problem with that. Okay. Some of the comments had, what about when you know that a person does not want to be a burden on their family? And that is their primary reason for requesting made. And the family may say, no, no, no, we will take care of you. But the person says, no, I just do not want to be a burden. How do you deal with that? Yeah, that's always tough. I think it causes some distress. I actually, personally, what I do is I pop that bubble. I tend to throw that back at patients and say, I'm not going to be that doctor that's going to lie to you and say, you're not a burden. In fact, you are. I mean, this is a burden. It's burdensome to take care of someone. But let's put the shoe on the other foot. If your wife was the one in bed and you were the one taking care of her, would you do that? And would you consider that burdensome? Well, you might consider it burdensome, but you'd also be willing to do it. My bet is because you've been together for 52 years and this is what you do for your partner. So that's not really, that's not a reason. That's not the reason. Our law does require the patient to be suffering. Could they be suffering significantly and intolerably by the concept of burdening their loved ones? I suppose that's a subjective debate we could maybe have. But generally speaking, because you feel you're a burden on someone is not really a reason to have made. So we'd have to explore that a little bit more. Sounds like a lot of the discretion really does come to the provider. And you obviously are very thoughtful about this. Do you worry that others are a little bit more knee-jerk or, you know? Well, I have developed very large and broad shoulders doing this work. There's a lot of responsibility. My experience, I'm in touch with colleagues across the country with my work in CAMAP. I have to tell you, the clinicians I work with, the clinicians I know, they take this pretty seriously. We have a criminal liability, right? If we don't do this right, we're liable for 14 years in jail. I don't know anyone who's looking to be an outlier, to be an activist, to be the, you know, the Kvorkian, the one to change the law. That's not what we're seeing. People are cautious. And the organization CAMAP is specifically there to help standardize care, to help, you know, help colleagues bring some up, pull others in so that we have a person in Nova Scotia who's got a particular situation, someone in Manitoba, they have the same type of approach to care, the same standard of care. It's really important that we do that. Now, not every clinician needs to be a member of our organization. I can't say that there's a quality control out there for every single clinician, but it has certainly not been my experience that there are, that anybody would sign off these papers with, you know, with just a quick glance. This is rigorous stuff that people take pretty seriously. You talked a little bit about palliative care and how you in Canada have fairly good access to palliative care. I know some of my friends when this last came to a vote in Massachusetts voted against it because they thought it had too great of a risk of allowing governments and insurance companies to take their foot off the gas around providing palliative care, that it was a cheaper and easier way out and that the only way to really maintain our focus on the need for good palliative care was to not have physician aid in dying. Of course, you know, that's not your situation in Canada, and I hesitate to have you comment on the United States experience, but I mean, I think for many people that's a big area of concern. And I think that there is a good example. I mean, if you look at the Belgians when they first started dealing with this care, they modeled, they not invented, they created what they call integrated end of life care, where palliative care and assisted dying, what they call euthanasia came up together, were linked together, needed to be happening together. In every jurisdiction where aid in dying has been legalized, we've seen a concurrent increase in palliative care funding and access if you look at the global data. So I think that the fears are legitimate, but have so far been unfounded. I think you can also create a situation or legislation that links the two. So that ensures that both come up together. I think that's probably essential. I mean, everybody who does assisted dying works wants the best palliative care possible for our patients because if that's satisfactory, they won't need this care, right? That would be ideal. We know that palliative care isn't the answer to everything and that despite good palliative care, people will still choose to have an assisted death, but it certainly makes us feel better to know they've had palliative care first. So I think you can link the two and I don't think that you should hold certain care or certain patients hostage to care system failings, right? I mean, it's not really, just because the resource isn't resourced, it doesn't mean you shouldn't offer something else. I think you need to do both at the same time. I think I really think that's the answer. All right, so let me comment here. Lachlan Farah who chaired our Massachusetts task force on end of life care asked the following. He says Massachusetts has been grappling with legislation on this, which has largely been a near copycat of the 30 year old Oregon statute. And we have learned a lot since then. Question is, what would be the ideal process for engaging diverse voices in creating legislation that can pass? And is there a state in the United States that you think has done this best? And do you have any suggestions about best sources of model legislation that we should review and possibly adopt? Great questions. I think I will be bold enough to say the answer to the first part of that question, the best way to engage and learn from others. I do think you need to look outside the borders. I do think there are, there's a number of jurisdictions with good data. The Australians got two and a half years of data. Canadians have five years of data. The Belgians, the Dutch, there's 20 years of data. There are other models that should be looked at. I've had international folks come and approach us in Canada to ask for our experience to seek that input. I do think there are good centers that you can contact and do that. I think it's very important you point out that we've got 23 years of experience. I do think we've learned a lot. I don't know the minutiae of the variations within the states. I am aware that in Mexico, one of the most recent states has been a little bit more forward thinking. I mean, at the very basics, they don't only allow physicians to do this, advanced practice and nurse practitioners can do this in New Mexico. I think that's the kind of thing that we've learned. Seeing in other jurisdictions have data on showing that it's safe and it's within scope of practice and now could be implemented based on that learning. New Zealand's done the same. I think with issues like clinician administered care, I think I would be a really tough one perhaps in the states, but there's really good data why it's a good idea. So I think engaging those outside of the US is important. Within the US, I wouldn't deem to answer which is the best state legislation to look at. That's out of my scope. But that is what could probably tell you that answer. To be honest. So here's a question. I guess it's about disabilities and about the deep bias we have around not valuing people who have disabilities and that there's no quick and easy way to just chuck that box and say, oh, we took that into account. We're not, that wasn't a factor here. How do you deal with that as a much deeper social problem about the worth of people with disabilities and their perceived worth and how they even perceive themselves? Yeah, it's a really good question. I think a couple of things. First and foremost, let me just say that, and this is not a cop out, but it's probably offensive to people, whether they're disabled or not, to think that they could be coerced into a decision by someone else, right? I mean, this care has to be explicitly requested and consented to by the patient themselves. So the idea that someone could convince them to do this, I think is offensive to a lot of people. That said, obviously society has certain views and they're not always so positive. I think also I would point out that there is a wide diversity, heterogeneity of the thought on assisted dying from within what we call the disabled community. I mean, I'm not even sure how you define this disabled community anymore, but there's, in fact, in Canada, much of our legislation, much of our court challenges have come from those with obvious physical disabilities who were arguing for the right to access to this care that they felt discriminated against because of their disability, they couldn't access this care. So I think it would be naive to think that there's one voice coming there and that's really opposed to this. It's quite not the case. So I would point that out. Having said that, it's now been a year where we have legislation where those who don't need to be anywhere near end of life can now access this care. And we are facing really challenging situations where people have come to us and asked for care because they are literally suffering for want of better resources that aren't available to them in the community, mental health resources, disability resources, social housing, things that I can't control and that I can't even find for them even if I wanted to. So what do I do when the patient meets all the eligibility requirements, tick, tick, tick, but it's because I see that it's for lack of resources. That's a situation that I can tell you providers are not comfortable with. We're not seeing those patients going forward, not necessarily because they don't meet the law, but because things are feeling a lot of moral tension around that. And while I say, it's easy to say, we need to work on both at the same time. And I think we are pushing for that. And I hope that assisted dying like with palliative care has brought palliative care to the conversation and brought into the headlines and brought more finance and funding the palliative care. I hope assisted dying will do the same for disability resources and mental health resources. I think it's one of the powers that this talk and this conversation, this topic can do. We can raise awareness of all of these issues. But practically speaking at the front of the line at the end of the day, I'm not so sure I'm comfortable, providing assisted dying for someone in that situation. I haven't done that yet. I'm not sure what I would do in that situation. It's a big, a big complication for sure. Dr. Green, we're in the last few seconds of our webinar here. Any last messages for, what did you call us earlier? The great behemoth to the south? The great behemoth to the south, yes. Our friendly southern neighbors. Any last comments for us? Advice, thoughts of wisdom? So many, but related to this topic. Yeah, no, I think keeping an open mind, keeping curious about what others have done that have gone before you. I think having the debate is important. I think having the conversation is the most important. I think that as clinicians, I think doing this work is not so far out of our wheelhouse. And I really feel strongly about that. I think you can get a better sense of that through my book. And I would only just say two things that clinicians that do this work are very, very conscientious about doing it, like everything else we do in medicine, right? We're conscientious about, before we cut into someone, we are also before this. And I can just reemphasize the work I've been overwhelmed with the gratitude from patients and families to have this possibility given to them. And the work has been very, very, very meaningful. So don't close your eyes to it. Thank you very much. It was a wonderful presentation today. We're very grateful to you for taking the time to do this. Thanks, Bob. Bye everyone, and thank you for being here with us.