chapter S-32.0001
AN ACT RESPECTING END-OF-LIFE CARE
TITLE I
PURPOSE
OF ACT
1. The purpose of this Act is to ensure that
end-of-life patients
are provided care that is respectful of their dignity and their
autonomy.
The Act establishes the rights of such patients
as well as the organization of and a framework for end-of-life care
so that everyone may have access, throughout the continuum of care,
to quality care that is appropriate to their needs,
including prevention and relief of suffering.
In addition, the Act recognizes the primacy
of
freely and clearly expressed wishes with respect to care,
in particular by establishing an advance medical directives regime.
2014, c. 2, s. 1.
TITLE II
END-OF-LIFE
CARE
CHAPTER I
GENERAL
PROVISIONS
2. The provision of end-of-life care is to be guided
by the following principles:
(1) respect for
end-of-life patients and recognition of their rights and freedoms
must inspire every act performed in their regard;
(2) end-of-life
patients must be treated, at all times,
with understanding, compassion, courtesy and fairness,
and with respect for their dignity, autonomy, needs and safety; and
(3) the
healthcare team providing care to end-of-life patients
must establish and maintain open and transparent communication with
them.
2014, c. 2, s. 2.
3. For the purposes of this Act,
(1) “institution” means
any institution governed by the Act
respecting health services and social services (chapter S-4.2)
that operates a local community service centre,
a hospital centre or a residential and long-term care centre,
as well as the Cree Board of Health and Social Services of James Bay
established under the Act respecting health services and social
services
for Cree Native persons (chapter S-5);
(2) “palliative care hospice” means a community
organization
that holds an accreditation granted by the Minister
under the second paragraph of section 457 of the Act
respecting health services and social services
and has entered into an agreement with an institution under section
108.3 of that Act
in order to secure all or some of the care required by its users;
(3) “end-of-life care” means
palliative care provided to end-of-life patients
and medical aid in dying;
(4) “palliative care” means
the total and active care
delivered by an interdisciplinary team
to patients suffering from a disease with reserved prognosis,
in order to relieve their suffering, without delaying or hastening
death,
maintain the best quality of life possible
and provide them and their close relations the support they need;
(5) “continuous palliative sedation” means care that is offered
as part of palliative care
and consists in administering medications or substances to an
end-of-life patient
to relieve their suffering by rendering them unconscious without
interruption until death ensues; and
(6) “medical aid in dying” means care consisting in
the administration
by a physician of medications
or
substances to an end-of-life patient,
at the patient's request, in order to relieve their suffering by
hastening death.
2014, c. 2, s. 3.
CHAPTER II
RIGHTS
WITH RESPECT TO END-OF-LIFE CARE
4. Every person whose condition requires it has the
right to receive end-of-life care,
subject to the specific requirements established by this Act.
Such care is provided to the person
in a facility maintained by an institution, in a palliative care
hospice or at home.
This section applies within the framework of the
legislative and regulatory provisions
relating to the organizational and operational structure of
institutions
and the policy directions, policies and approaches of palliative care
hospices
and within the limits of the human, material and financial resources at
their disposal.
It complements the provisions of the Act respecting health services and
social services (chapter S-4.2)
and of the Act respecting health services and social services for Cree
Native persons (chapter S-5)
that relate to the rights of users and beneficiaries.
2014, c. 2, s. 4.
To the extent provided by the Civil Code, a minor
of 14 years of age or over,
and in the case of a minor or a person of full age who is incapable of
giving consent,
the person who may give consent to care on their behalf may also make
such a decision.
The refusal of care or withdrawal of consent to
care may be expressed by any means.
2014, c. 2, s. 5.
6. A person may not be denied end-of-life care
for previously having refused to receive certain care
or having withdrawn consent to certain care.
2014, c. 2, s. 6.
CHAPTER III
ORGANIZATION
OF END-OF-LIFE CARE
DIVISION I
SPECIAL
RULES APPLICABLE TO PROVIDERS OF END-OF-LIFE CARE
§ 1. — Institutions
7. Every institution must offer end-of-life care
and ensure that it is provided to the persons requiring it
in continuity and complementarity with any other care that is or has
been provided to them.
For this purpose, an institution must, among other
things, establish measures to promote
a multiple-discipline approach by health and social services
professionals
and the collaboration of the various other resources concerned who
provide services to its users.
2014, c. 2, s. 7.
8. Every institution must adopt a policy with respect
to end-of-life care.
The policy must be consistent with ministerial policy directions
and be made known to the personnel of the institution,
to the health and social services professionals who practise in the
institution,
and to end-of-life patients and their close relations.
The executive director of the institution must
report annually
to the board of directors on the carrying out of the policy.
The report must include the number of end-of-life patients who received
palliative care,
the number of times continuous palliative sedation was administered,
the number of requests for medical aid in dying,
the number of times such aid was administered
as well as the number of times medical aid in dying was not
administered,
including the reasons it was not administered.
The report must also state, where applicable, the
number of times
continuous palliative sedation and medical aid in dying were
administered
at the patient's home or in the premises of a palliative care hospice
by a physician as a physician practising in a centre operated by the
institution.
The report is to be published on the website of
the institution
and sent, not later than 30 June each year,
to the Commission sur les soins de fin de vie established under section
38.
The institution must include a summary of the report
in a separate section of its annual management report.
2014, c. 2, s. 8.
9. Every institution must include a clinical program
for end-of-life care in its organization plan.
In the case of an institution that operates a local community service
centre,
the plan must also include the provision of end-of-life care at the
patient's home.
The organization plan must be consistent with
ministerial policy directions.
The clinical program for end-of-life care is to be
sent to the Commission sur les soins de fin de vie.
2014, c. 2, s. 9.
10. The code of ethics adopted by an institution
under section 233 of the Act respecting health services and social
services (chapter S-4.2)
must have due respect for the rights of end-of-life patients.
2014, c. 2, s. 10.
11. When an end-of-life patient requests in-home
palliative care from an institution,
but the person's condition or environment is such that proper care
could not be provided at home,
the institution must offer to admit the person to its facilities
or direct them to another institution or to a palliative care hospice
that can meet their needs.
2014, c. 2, s. 11.
12. An institution must offer every patient receiving
end-of-life care
a private room for the final few days preceding the patient's death.
2014, c. 2, s. 12.
§ 2. — Palliative
care hospices
13. Palliative care hospices determine the end-of-life
care provided in their premises.
Every palliative care hospice must inform persons
of the end-of-life care it offers before admitting them.
2014, c. 2, s. 13.
14. A palliative care hospice and an institution must
specify in their agreement
under section 108.3 of the Act respecting
health services and social services (chapter
S-4.2)
the nature of the services the institution is to provide
in the premises of the hospice
and the monitoring mechanisms that will
allow the institution,
or one of its boards, councils or committees
determined in the agreement,
to ensure that quality care is provided in
the hospice.
On the request of the institution, the palliative
care hospice must communicate
any information required for the carrying
out of the agreement.
The manner in which such information is to be
communicated is specified in the agreement.
2014, c. 2, s. 14.
15. Every palliative care hospice must adopt a code of
ethics
with respect to the rights of end-of-life patients
and adopt a
policy with respect to end-of-life care.
These documents must be made known to the
personnel of the palliative care hospice,
to the health and social
services professionals who practise in the hospice,
and to end-of-life
patients and their close relations.
2014, c. 2, s. 15.
§ 3. — Private
health facilities
16. End-of-life care may be provided at the patient's
home
by physicians practising in a private health facility
within the
meaning of section 95 of the Act
respecting health services and social
services (chapter S-4.2)
and, within
their scope of practice, by nurses practising in such a facility.
2014, c. 2, s. 16.
DIVISION II
SPECIAL
FUNCTIONS OF HEALTH AND SOCIAL SERVICES AGENCIES
17. Every health and social services agency must,
after consultation with the institutions and palliative care hospices
in its territory,
determine the general rules governing access to the
end-of-life care
provided by those institutions and hospices.
2014, c. 2, s. 17.
18. Every agency must inform the population living in
its territory
of the end-of-life care services available and the manner
of accessing them,
as well as the rights and options of end-of-life
patients.
This information must be available on the websites
of the agencies.
2014, c. 2, s. 18.
DIVISION III
SPECIAL
FUNCTIONS AND POWERS OF THE MINISTER
19. The Minister determines the policy directions that
are to guide institutions
and agencies when organizing end-of-life
care,
including those which institutions must take into account
when
formulating their end-of-life care policy.
2014, c. 2, s. 19.
20. The Minister may require of institutions,
palliative care hospices and agencies that they supply,
in the manner
and within the time specified,
statements, statistical data, reports
and other information
required for the performance of the functions
vested in the Minister under this Act,
provided it is not possible to
link that information
to any specific patient having received
end-of-life care
or to any specific health or social services
professional having provided the care.
2014, c. 2, s. 20.
21. In order to ascertain compliance with this Title,
a person authorized in writing by the Minister to carry out an
inspection may,
at any reasonable time, with due respect for the
specific character of the premises
and the needs of the persons
receiving end-of-life care,
enter any premises operated by an
institution or a palliative care hospice.
The person may, during an inspection,
(1) examine and
make a copy of any document
relating to the end-of-life care offered in
those premises; and
(2) demand any
information relating to the carrying out of this Title
as well as the
production of any related document.
Any person having custody, possession or control
of such documents
must make them available on request to the person
conducting the inspection.
A person conducting an inspection must, if so
required, produce a certificate of capacity.
Any person who hinders a person in the conduct of
an inspection,
refuses to provide any information or document the
latter is entitled to require or examine,
or conceals or destroys any
document or other object relevant to an inspection
is guilty of an
offence and is liable to a fine of $2,500 to $25,000
in the case of a
natural person and to a fine of $7,500 to $75,000 in any other case.
2014, c. 2, s. 21.
22. The Minister may delegate the powers provided for
in section 21
to a health and social services agency.
The agency informs the Minister of the designation
of an inspector
and of the results of the inspection.
2014, c. 2, s. 22.
23. A person authorized in writing by the Minister
or,
where applicable, by an agency to carry out an inspection
may not be
prosecuted for an omission or an act done in good faith
in the
performance of their duties.
2014, c. 2, s. 23.
CHAPTER IV
SPECIAL
REQUIREMENTS FOR CERTAIN END-OF-LIFE CARE
DIVISION I
CONTINUOUS
PALLIATIVE SEDATION
In addition, the physician must make sure that the
request is being made freely,
in particular by ascertaining that it is
not being made as a result of external pressure.
Consent
to
continuous palliative sedation must be
given in writing
on the form prescribed by the Minister and be filed in
the patient's record.
2014, c. 2, s. 24.
25. If the patient giving consent to continuous
palliative sedation
cannot date and sign the form referred to in
section 24
because the patient cannot write or is physically incapable
of doing so,
a third person may do so in the patient's presence.
The
third person may not be a member of the team responsible for caring for
the patient,
a minor or a person of full age incapable of giving
consent.
2014, c. 2, s. 25.
DIVISION II
MEDICAL
AID IN DYING
26. Only a patient who meets all of the following
criteria may obtain medical aid in dying:
(1) be an
insured
person
within the meaning of the Health Insurance Act (chapter A-29);
(5) be in an
advanced state of irreversible decline in capability; and
The form must be signed in the presence of
and
countersigned by a health or social services professional;
if the
professional is not the attending physician,
the signed form is to be
given by the professional to the attending physician.
2014, c. 2, s. 26.
27. If the patient requesting medical aid in dying
cannot date and sign the form referred to in section 26
because the
patient cannot write or is physically incapable of doing so,
a third
person may do so in the patient's presence.
The third person may not be
a member of the team responsible for caring for the patient,
a minor or
a person of full age incapable of giving consent.
2014, c. 2, s. 27.
A patient may also, at any time and by any means,
request that the administration of medical aid in dying be
put off.
2014, c. 2, s. 28.
29. Before administering medical aid in dying, the
physician must
(1) be of the
opinion that the patient meets all the criteria of section 26,
after,
among other things,
(a) making sure
that the request is being made freely,
in particular by ascertaining
that it is not being made as a result of external pressure;
The physician consulted must be independent
of
both the patient requesting medical aid in dying
and the physician
seeking the second medical opinion.
The physician consulted must
consult the patient's record,
examine the patient and provide
the
opinion in writing.
2014, c. 2, s. 29.
30. If a physician determines, subsequent to the
application of section 29,
that medical aid in dying may be
administered to a patient requesting it,
the physician must administer
such aid personally
and take care of and stay with the patient until
death ensues.
If the physician determines that medical aid in
dying cannot be administered,
the physician must inform the patient of
the reasons for that decision.
2014, c. 2, s. 30.
31. A physician practising in a centre operated by an
institution
who refuses a request for medical aid in dying for a reason
not based on section 29
must, as soon as possible, notify the executive
director of the institution
or any other person designated by the
executive director
and forward the request form given to the physician,
if that is the case,
to the executive director or designated person.
The executive director of the institution or designated person
must
then take the necessary steps to find, as soon as possible, another
physician
willing to deal with the request in accordance with
section 29.
If the physician who receives the request
practises in a private health facility
and does not provide medical aid
in dying,
the physician must, as soon as possible, notify
the executive
director of the local authority referred to in section 99.4
of the Act
respecting health services and social services (chapter S-4.2)
that serves the territory in
which the patient making the request resides,
or notify the person
designated by the executive director.
The physician forwards the
request form received, if that is the case,
to the executive director
or designated person
and the steps mentioned in the first paragraph
must be taken.
If no local authority serves the territory in
which the patient resides,
the notice referred to in the second
paragraph is forwarded
to the executive director of the institution
operating a local community service centre
in the territory or the
person designated by the executive director.
2014, c. 2, s. 31.
32. All
information
and documents in connection with a
request for medical aid in dying,
regardless of whether the physician
administers it or not,
including the form used to request such aid, the
reasons for the physician's decision
and, where applicable, the opinion
of the physician consulted,
must be recorded or filed in the patient's
record.
2014, c. 2, s. 32.
DIVISION III
SPECIAL
FUNCTIONS OF THE COUNCIL OF PHYSICIANS, DENTISTS AND PHARMACISTS
33. The council of physicians, dentists and
pharmacists established for an institution
must, in collaboration with
the council of nurses of the institution,
adopt clinical protocols for
continuous palliative sedation and medical aid in dying.
The protocols
must comply with the clinical standards
developed by the professional
orders concerned.
2014, c. 2, s. 33.
34. A physician who provides continuous palliative
sedation or medical aid in dying
as a physician practising in a centre
operated by an institution
must, within 10 days following its
administration,
inform the council of physicians, dentists and
pharmacists
of which the physician is a member,
whether it is
administered in the facilities of an institution,
in the premises of a
palliative care hospice or at the patient's home.
The council of physicians, dentists and
pharmacists or its competent committee
assesses the quality of the care
provided,
particularly with regard to applicable clinical protocols.
2014, c. 2, s. 34.
35. If no council of physicians, dentists and
pharmacists is established for the institution,
the head of medical
services or the physician responsible for medical care in the
institution,
as applicable, assumes the functions assigned to the
council under this division,
and the physician informs that person in
accordance with the first paragraph of section 34.
2014, c. 2, s. 35.
DIVISION IV
SPECIAL
FUNCTIONS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC
36. Physicians practising in a private health facility
that provides continuous palliative sedation or medical aid in dying
at
the patient's home or in the premises of a palliative care hospice
must, within 10 days following its administration,
inform the
Collège des médecins du Québec and send to it,
under the conditions and in the manner prescribed by the
Collège,
the information it determines.
The Collège or its competent committee
assesses the quality of the care provided,
particularly with regard to
applicable clinical standards.
2014, c. 2, s. 36.
37. The Collège des médecins du
Québec must prepare a yearly report
on the end-of-life care
provided by physicians practising in private health facilities.
The report must state the number of times
continuous palliative sedation and medical aid in dying were
administered
by such physicians at the patient's home or in the
premises of a palliative care hospice.
The information must be grouped
by local health and social services network territory
and health and
social services agency territory.
The report is to be published on the website of
the Collège and sent,
not later than 30 June each year, to the
Commission sur les soins de fin de vie.
2014, c. 2, s. 37.
CHAPTER V
COMMISSION
SUR LES SOINS DE FIN DE VIE
DIVISION I
ESTABLISHMENT
AND FUNCTIONING OF THE COMMISSION
38. A commission on end-of-life care (“the
Commission”) is established
under the name “Commission sur les soins de
fin de vie”.
2014, c. 2, s. 38.
39. The Commission is composed of 11 members,
appointed by the Government as follows:
(1) five members
are to be health or social services professionals, including
(a) two members
appointed after consultation with the Collège des
médecins du Québec;
(b) one member
appointed after consultation with the Ordre des infirmières et
infirmiers du Québec;
(c) one member
appointed after consultation with the Ordre des pharmaciens du
Québec; and
(d) one member
appointed after consultation with the Ordre professionnel
des
travailleurs sociaux et des thérapeutes conjugaux et familiaux
du Québec;
(2) two members
are to be jurists, appointed after consultation
with the Barreau du
Québec and the Chambre des notaires du Québec;
(3) two members
are to be users of institutions,
appointed after consultation with
bodies representing the users' committees of institutions;
(4) one member
is to be from the ethics community,
appointed after consultation with
university-level educational institutions; and
(5) one member
is to be appointed after consultation with bodies representing
institutions.
The Government must ensure that at least one
member
appointed under subparagraph 1 of the first paragraph is from
the palliative care community.
The members of the Commission are appointed for a
term of not more than five years.
Their terms of office may be renewed
consecutively only once.
At the expiry of their terms, members remain
in office until they are replaced or reappointed.
The Government designates,
from among the members
of the Commission, a chair and vice-chair;
the vice-chair shall chair
the Commission when the chair is absent or unable to act.
The Government fixes the allowances and
indemnities of the members of the Commission.
2014, c. 2, s. 39.
40. The Commission may make by-laws concerning its
internal management.
2014, c. 2, s. 40.
41. The quorum at meetings of the Commission is seven
members,
including the chair or the vice-chair.
Subject to the second paragraph of section 47,
the
decisions of the Commission are made by a majority vote of the members
present.
In the case of a tie vote, the person presiding at the meeting
has a casting vote.
2014, c. 2, s. 41.
DIVISION II
MANDATE
OF THE COMMISSION
42. The mandate of the Commission is to examine any
matter relating to end-of-life care.
For this purpose, it must, among
other things,
(1) advise the
Minister on any matter put before it by the Minister;
(2) evaluate the
implementation of legislation with regard to end-of-life care;
(3) refer to the
Minister any matter relating to end-of-life care
that needs the
attention of or action by the Government,
and submit its
recommendations to the Minister;
(4) submit a
report to the Minister, every five years,
on the status of end-of-life
care in Québec; and
(5) carry out
any other mandate given to it by the Minister.
The Commission also has the mandate
of overseeing
the application of the specific requirements
relating to medical aid in
dying in compliance with this division.
The Commission is to submit an annual activity
report,
not later than 30 September each year, to the Minister.
2014, c. 2, s. 42.
43. The Minister tables the reports produced by the
Commission
in the National Assembly within 30 days of receiving them
or, if the Assembly is not sitting, within 30 days of resumption.
The
competent committee of the National Assembly examines the reports.
2014, c. 2, s. 43.
44. In exercising its functions under the first
paragraph of section 42,
the Commission may, as an exception, take such
measures as
(1) soliciting
the opinion of individuals or groups on any end-of-life care issue;
(2) conducting
or commissioning studies and research it deems necessary; and
(3) calling on
outside experts to report to it on one or more specific points.
2014, c. 2, s. 44.
45. The Commission may require of institutions,
palliative care hospices,
physicians practising in a private health
facility and agencies that they supply,
in the manner and within the
time specified, the statements, statistical data,
reports and other
information it needs for the performance of its functions
under the
first paragraph of section 42,
provided it is not possible to link that
information to any specific patient
having received end-of-life care
or
to any specific health or social services professional having provided
the care.
2014, c. 2, s. 45.
46. A physician who administers medical aid in dying
must give notice to the Commission within the next 10 days and send the
Commission,
in the manner determined by government regulation, the
information prescribed by regulation.
This information is confidential
and may not be disclosed to any other person,
except to the extent that
is necessary for the purposes of this section and section 47.
Any person who notes that a physician has
contravened this section
must bring the breach to the attention of the
Collège des médecins du Québec
so that it can take
appropriate measures.
2014, c. 2, s. 46.
47. On receiving the notice from the physician,
the
Commission assesses compliance with section 29
in accordance with the
procedure prescribed by government regulation.
On completion of the assessment, if two thirds or
more of the members present
are of the opinion that section 29 was not
complied with,
the Commission sends a summary of its conclusions to the
Collège des médecins du Québec
and, when the
physician provided the medical aid in dying
as a physician practising
in a centre operated by an institution,
to the institution concerned so
that they can take appropriate measures.
2014, c. 2, s. 47.
CHAPTER VI
MISCELLANEOUS
PROVISIONS
48. Complaints regarding end-of-life care
made by any
person to a local or regional service quality complaints commissioner,
in accordance with the rules prescribed
in Divisions I to III of
Chapter III of Title II of Part I of the Act
respecting health services
and social services (chapter S-4.2),
must be given priority treatment.
The same applies to complaints
regarding end-of-life care
made to the syndic of the Collège des
médecins du Québec.
2014, c. 2, s. 48.
49. The decision of a patient or, where applicable,
of
the person who may give consent to care on the patient's behalf
to
refuse certain life-sustaining care or withdraw consent to such care
or
to request continuous palliative sedation or medical aid in dying
may
not be invoked as a reason to refuse to pay a benefit
or any other sum
due under a contract.
2014, c. 2, s. 49.
50. A physician may refuse to administer medical aid
in dying
because of personal convictions,
and a health professional may
refuse to take part in administering it for the same reason.
In such a case, the physician or health
professional
must nevertheless ensure that continuity of care is
provided to the patient,
in accordance with their code of ethics and
the patient's wishes.
In addition, the physician must comply with the
procedure established in section 31.
2014, c. 2, s. 50.
TITLE III
ADVANCE
MEDICAL DIRECTIVES
CHAPTER I
GENERAL
PROVISIONS
51. A person of full age who is capable of giving
consent to care may,
by means of advance
medical directives, specify
whether or not they consent to care
that may be required by their state
of health,
in the event they become incapable of giving consent.
However, in such directives the person may not request medical aid in
dying.
2014, c. 2, s. 51.
52. Advance medical directives are given by notarial
act en minute
or in the presence of
witnesses on the form prescribed by the Minister.
not in force
At the request of their author, advance medical
directives are to be recorded
in the advance medical directives
register established under section 63.
2014, c. 2, s. 52.
53. When advance medical directives are given in the
presence of witnesses,
the form must be completed by the person
concerned.
The person then declares, in the presence of two
witnesses,
that the form contains the person's advance medical
directives,
without having to disclose the contents.
The person dates
and signs the form
or, if this is already done, recognizes the
signature as their own.
The form is then signed by the witnesses in the
person's presence.
If the person cannot complete the form
because the
person cannot write or is physically incapable of doing so,
it may be
completed by a third person in accordance with the person's
instructions.
The third person signs and dates the form in the person's
presence.
Persons of full age incapable of giving consent
and minors
cannot act as a third person or a witness for the purposes
of this section.
2014, c. 2, s. 53.
54. Advance medical directives may be revoked at any
time
by the person concerned by means of the form prescribed by the
Minister.
Such directives may only be changed by writing new
ones
by one of the methods specified in the first paragraph of section
52.
The new directives replace any previous ones.
Despite the first and second paragraphs, in
emergency cases,
if a person capable of giving consent to care verbally
expresses wishes
different from those in their advance medical
directives,
this entails the revocation of the directives.
2014, c. 2, s. 54.
55. When advance medical directives are given to a
health professional,
that professional files them in the record of the
person concerned if this has not yet been done.
If the directives are
given to the health professional by the person concerned
and the person
is capable of giving consent to care,
the health professional must
first inquire whether they still correspond to the person's wishes.
2014, c. 2, s. 55.
56. A physician who notes a significant change
in the
state of health of a person capable of giving consent to care
must, if
advance medical directives have been filed in the person's record,
inquire whether the directives still correspond to the person's wishes.
2014, c. 2, s. 56.
not in force
57. A physician who notes that a person is incapable
of giving consent to care
consults the advance medical directives
register.
If the register contains advance medical directives for the
person,
the physician files them in the person's record.
2014, c. 2, s. 57.
58. When a person is incapable of giving consent to
care,
clearly expressed instructions relating to care
that are recorded
in the advance medical directives register
or filed in the person's
record carry,
for all health professionals having access to the
register or record,
the same weight as wishes expressed by a person
capable of giving consent to care.
2014, c. 2, s. 58.
This section is not in force
to the extent that it
concerns the advance medical directives register.
59. The author of advance medical directives
is
presumed to have been in the possession of the information needed
to
make an informed decision at the time of signing the directives.
2014, c. 2, s. 59.
60. If a person incapable of giving consent to care
categorically refuses care
which they had previously consented to in
advance medical directives,
article 16 of the Civil Code, requiring the
authorization of the court, applies.
2014, c. 2, s. 60.
61. The court may, on the application of the
mandatary, tutor, curator of
or any person showing a special interest
in the author of advance medical directives,
order that the
instructions relating to care expressed in those directives be carried
out.
The court may also, on the application of such a
person, a physician or an institution,
invalidate advance medical
directives, in full or in part,
if it has reasonable grounds to believe
that the author of the directives
was not capable of consenting to the
care at the time of signing the directives
or that the directives do
not correspond to the author's wishes in the present situation.
The court may, in addition,
make any other order
it considers appropriate in the circumstances.
2014, c. 2, s. 61.
62. Instructions relating to care expressed in a
protection mandate
do not constitute advance medical directives within
the meaning of this Act
and remain subject to articles 2166 and
following of the Civil Code.
In case of inconsistency between those
instructions for care
and the instructions contained in advance medical
directives, the latter prevail.
2014, c. 2, s. 62; I.N. 2016-01-01 (NCCP).
CHAPTER II
ADVANCE
MEDICAL DIRECTIVES REGISTER
63. The Minister establishes and maintains an advance
medical directives register.
The Minister may manage the register or entrust
its management to a body
that is subject to the Act respecting Access
to documents held by public bodies
and the Protection of personal
information (chapter A-2.1).
In the
latter case, the Minister enters into a written agreement with the
manager.
2014, c. 2, s. 63.
64. The Minister prescribes, by regulation,
how the
register is to be accessed and operated,
including who may record
advance medical directives in the register and who may consult it.
2014, c. 2, s. 64.
TITLE IV
AMENDING,
TRANSITIONAL AND FINAL PROVISIONS
CHAPTER I
AMENDING
PROVISIONS
CIVIL CODE OF QUÉBEC
65. (Amendment
integrated into the Civil Code, a. 11).
2014, c. 2, s. 65.
66. (Amendment
integrated into the Civil Code, a. 12).
2014, c. 2, s. 66.
67. (Amendment
integrated into the Civil Code, a. 15).
2014, c. 2, s. 67.
CODE OF CIVIL PROCEDURE
68. (Amendment
integrated into c. C-25, a. 776).
2014, c. 2, s. 68.
MEDICAL ACT
69. (Amendment
integrated into c. M-9, s. 31).
2014, c. 2, s. 69.
PHARMACY ACT
70. (Amendment
integrated into c. P-10, s. 17).
2014, c. 2, s. 70.
ACT RESPECTING HEALTH SERVICES AND SOCIAL SERVICES
71. (Amendment
integrated into c. S-4.2, s. 19).
2014, c. 2, s. 71.
CHAPTER II
TRANSITIONAL
AND FINAL PROVISIONS
72. Despite section 7, an institution which, on 10
December 2015,
operates a general and specialized hospital centre and,
within the range of care that may be offered pursuant to the mission of
such a centre,
only offers palliative care may continue to offer that
care exclusively.
Such an institution must inform persons of the
end-of-life care it offers before admitting them.
2014, c. 2, s. 72.
73. Until 10 December 2017, executive directors of
institutions
must report every six months to their board of directors
as described in the second paragraph of section 8.
The institutions are
to forward the report to the Commission sur les soins de fin de vie
as
soon as possible and publish it on their website.
Until that date, the Collège des
médecins du Québec
is also to send the Commission the
report required under section 37 every six months.
2014, c. 2, s. 73.
74. Institutions and palliative care hospices have
until 10 December 2016
to amend the agreement they have entered into
under section 108.3
of the Act respecting health services and social
services (chapter S-4.2)
in order to
bring it into conformity with section 14.
2014, c. 2, s. 74.
75. Despite subparagraph 4 of the first paragraph of
section 42,
the Commission sur les soins de fin de vie must send its
first report
on the status of end-of-life care not later than 10
December 2018.
2014, c. 2, s. 75.
76. The Minister must, not later than 10 December
2019,
report to the Government on the implementation of this Act,
and
subsequently every five years, report to the Government on the carrying
out of this Act.
Such report is tabled by the Minister in the
National Assembly within the next 30 days
or, if the Assembly is not
sitting, within 30 days of resumption.
The report is examined by the
competent committee of the National Assembly.
2014, c. 2, s. 76.
77. The Minister of Health and Social Services is
responsible for the administration of this Act.
2014, c. 2, s. 77.
78. (Omitted).
2014, c. 2, s. 78.
COMMENTS ON QUEBEC'S
RIGHT-TO-DIE LAW
by James Leonard Park
OUTLINE:
1. THE NUMBER OF DEATHS
INCLUDED IN THE LEGISLATION
2. QUEBEC'S RIGHT-TO-DIE LAW
DOES NOT
CONFLICT WITH CANADIAN NATIONAL
LAWS
3. ADDITIONAL DEFINITIONS
NEEDED
4. ADDITIONAL METHODS OF
CHOOSING DEATH COULD BE INCLUDED
5. ALL HEALTH-CARE
INSTITUTIONS MUST
PROVIDE END-OF-LIFE CARE
6. ALL THE EMBEDDED SAFEGUARDS
COULD BE GATHERED INTO ONE PLACE
~~~~~~~~~~~
1. THE NUMBER OF DEATHS INCLUDED IN THE LEGISLATION
Having analyzed several
other
laws and proposed laws concerning the right-to-die,
in my opinion, Quebec's Act Respecting End-of-Life 'Care
has the potential to cover more
deaths than any other right-to-die legislation.
This is because it mentions refusing
medical treatment and terminal
sedation
as well as "medical aid in
dying".
According to estimates
explained here,
withdrawing or withholding
medical treatments and life-supports
is the method of managing dying in 10-15% of all deaths
in countries with modern medicine.
Also terminal
sedation is another medical method of managing dying
used in 5-10% of all deaths.
These numbers are found in countries
that also permit the use of gentle
poison as a method of choosing death.
The doctor providing lethal chemicals to cause death
accounts for about 2% of all deaths in these countries.
Adding these medical methods of managing dying
together,
the totals come to 17-27% of all deaths.
This means that Quebec's law covers about 10 times as
many deaths
as legislation that only authorizes gentle poison provided by doctors.
If Quebec's law (or other laws adapted from it)
expands
to include
all 5 methods of managing dying discussed in Comment 4 below,
then over 50% of all
deaths in that jurisdiction will be covered.
2. QUEBEC'S RIGHT-TO-DIE LAW
DOES NOT
CONFLICT WITH CANADIAN NATIONAL
LAWS
On February 6, 2015, the Supreme Court of Canada
lifted the ban on 'assisted suicide' for all
of Canada.
With a 16-month delay to allow the Parliament of Canada
to enact new federal criminal laws with respect to the right-to-die,
the old laws and court rulings that might have prevented
reasonable end-of-life medical decisions were struck down.
When Bill 52 was first passed in Quebec (in 2014),
it probably did
contradict Canadian federal criminal law
especially Quebec's provision for "medical aid in dying".
But now the Supreme Court of Canada
has lifted the overly-broad ban on 'assisting suicide'.
And the Supreme Court of Canada
has explicitly permitted Quebec's law to go forward.
Canadian federal law covers all criminal matters.
(The organization of health care is left to the provinces.)
And until this ruling by the Supreme Court of Canada,
the federal Criminal Code prohibited and punished
committing euthanasia or assisting a suicide.
Now "medical aid in dying" will no longer be against
federal criminal law.
And the other mentioned methods of choosing death are still legal:
Refusing
further medical care intended to postpone death
is a legal and ethical option wherever modern medical care
prevails.
And terminal sedation
remains a medical option:
The doctor can order drugs to keep the patient unconscious until death
comes.
Both of these methods of managing the process of
dying
are well-recognized in most countries with modern medical care.
Only occasionally is there a legal challenge to either of these methods
of dying.
All doctors and patients will be assured by the
words of Quebec's right-to-die law
that (under reasonable standards of medical care)
it is legal to withdraw or withhold any and all medical treatments and
life-supports.
Also it is legal for a physician to order sufficient drugs
to keep the patient completely and permanently unconscious until death
occurs.
There are many other meaningful and useful
provisions of Quebec's law
which were never in conflict with Canadian national law.
For example, the Commission
on End-of-Life Care
and the Advance Directives
Registry
are major advances for terminal medical care.
(As noted in the text above, the Advance Directive Register
is not yet in effect.)
3. ADDITIONAL DEFINITIONS NEEDED
Refusing
any and all further medical treatments and life-supports
is probably clear enough all by itself.
But it would do no harm to define and describe these behaviors
at the beginning of the law.
For example, when is providing
food and water a medical treatment
that may therefore be refused under this law?
The expression "continuous palliative sedation"
will probably be clear to all lawyers and doctors.
But members of the general public who are not familiar with this
concept
would benefit from having it spelled out:
The doctor orders that the patient be kept
completely and permanently unconscious by means of sedative drugs
until natural death occurs.
Keeping the patient asleep
until death
is not the same as giving chemicals that cause
immediate death.
"Medical aid in dying" is defined for the first time
in this version of the law:
Chapter I, Section 3, item (6):
"Medical aid in dying" means care consisting in the administration
by a physician of medications or substances to the end-of-life patient,
at the patient's request, in order to relieve suffering and hasten
death.
4. ADDITIONAL METHODS OF CHOOSING DEATH COULD BE INCLUDED
More than most other legislation concerning the
right-to-die,
this law does take into account the ways modern medical care is now
provided.
Three out of five medical
methods
of managing dying are mentioned.
It would do no harm to name the other two,
which are very common in the modern hospital:
1. Increasing
pain-medication means
changing the dose of drugs already in use with the knowledge
that the same drugs being used to relieve pain and suffering
will probably also shorten the process of dying.
The laws of a few other countries (and states of the USA)
do recognize this modern medical practice.
And when the amount of drugs given are within standard terminal care,
no crime has been committed.
2. Medical
dehydration means giving up all food and water
with the knowledge that death will inevitably follow within a few days.
This change in medical treatment is usually ordered
when the patient is also being removed from
all other forms of curative
medical treatment and life-support.
And since section 5 of this law allows all forms of medical care to be
refused,
this could be interpreted to include
providing food and water by artificial means.
However, as said about increasing pain-medication,
it does no harm to put into unambiguous words
the practice of allowing doctors to order
that food and water be discontinued for this dying patient.
In short, five
medical methods of managing dying
could be named and described in any revised end-of-life law
(or any other right-to-die legislation adapted from Quebec's law):
1. increasing
pain-medication with the knowledge
that the process of dying might be shortened as a side-effect.
2. terminal
sedation
—keeping the patient permanently
asleep until death comes.
3. ending
all
curative medical treatments and life-supports.
4. withdrawing
or withholding food and water
with the certain knowledge that death will result.
5. gentle
poison provided by a doctor,
which could include lethal injections or death pills.
5. ALL HEALTH-CARE INSTITUTIONS
MUST
PROVIDE END-OF-LIFE CARE
Perhaps most casual readers of this law will read
right thru these provisions
without noticing that this is a major change in health-care
policy.
End-of-life care MUST include "palliative care" and "medical aid in
dying".
No institutions may exempt themselves from these services
by saying that it is against their religion or some other
consideration.
(Section 7 and following)
However, later in this law, individuals physicians
are
offered
the freedom to avoid involvement in life-ending decisions.
If Quebec's
right-to-die law is revised
to include
increasing pain-medication and medical dehydration,
these would also be approved
methods of choosing death
that must be
available in any health-care institution.
This pattern could also be followed by any other
province, state, or country
that adapts Quebec's right-to-die law for its own jurisdiction:
All health-care organizations could be required to provide
all of the named medical
methods of managing dying.
6. ALL THE EMBEDDED SAFEGUARDS
COULD BE
GATHERED INTO ONE PLACE
Opponents of the right-to-die often argue
that there are not enough safeguards to protect patients
in any legislation that allows life-ending decisions.
Quebec's "An Act Concerning End-of-Life Care"
contains at least 17 safeguards,
which are
organized at the beginning of this presentation.
These could all be gathered into just one place in the
legislation,
thereby allowing more careful fulfilling of the safeguards,
especially if they were named and/or numbered.
The documents proving that the safeguards have been fulfilled
could be gathered and numbered in the same order as they appear in the
law.
Whenever critics of the proposed legislation raise
doubts about the safeguards,
each safeguard could be evaluated on it own merits and weaknesses.
Doubts could be raised about how each safeguard might be applied.
Whenever such doubts are valid, that safeguard could be strengthened.
Gathering all of the safeguards into one location in
any proposed bill
will aid the legislative
process for making a new law.
Instead of merely rejecting all of the safeguards as weak and useless,
opponents would be called upon to address each safeguard individually.
Would this safeguard
prevent the mistakes and abuses they fear?
Also, any new law based on Quebec's right-to-die law
should make sure all
safeguards apply to all
the named methods of dying.
Here is an example of proposed legislation
that does put all 26 recommended safeguards into one section of the
law:
http://www.tc.umn.edu/~parkx032/PREM-DTH.html.
