Quebec Euthanasia report - Quebec has the highest euthanasia rate in the world.

FOR IMMEDIATE RELEASE (Link to the Press Release)

2024–2025 Report of the Commission on End-of-Life Care was released providing the Québec MAiD date from April 1, 2024 to March 31, 2025.

In the absence of representative data and a first report without a portrait of palliative care.

Meanwhile, Quebec remains the world leader in medical assistance in dying with 6,268 (7.9% of deaths)

Montreal, November 4, 2025 – The Commission on end-of-life care released its 2024–2025 Annual Report on October 30th (in French). After reviewing the document, the Living with Dignity citizen network (Vivre dans la Dignité) wishes to highlight two aspects of the report that must not go unnoticed in political and media discussions.

Medical assistance in dying: Quebec has the highest rate in Canada.

Quebec remains firmly positioned among the jurisdictions with the highest proportion of assisted deaths (MAiD, euthanasia, or assisted suicide), accounting for 7.9% of all deaths during the period studied—an increase of 9% compared to the previous year.

As Quebec approaches the 10th anniversary of its first cases of medical assistance in dying (December 10, 2025), the report raises several concerns regarding this practice, including:

• Major regional disparities (MAiD represented 13.4% of deaths in Lanaudière vs. 4.7% in Montreal), a nearly 20% increase in Montérégie, and more;
• Very short delays between a MAiD request and its administration (same day or next day in 4% of cases); 
• Non-compliance in a small number of cases (0.3%), with no reported disciplinary consequences in these 19 reported cases—one of which involved administration without the person’s consent at the time. Living with Dignity reiterates that the current self-reporting system for MAiD providers after deaths cannot offer a full picture of non-compliant cases; 
• 50% of those who received MAiD cited suffering from being perceived as a burden to family, friends, or caregivers; 24% cited loneliness and isolation.

In concluding its report, the Commission reminds readers of its duty to ensure that MAiD is not “chosen for lack of access to other curative, palliative, or end-of-life care that is of high quality and adapted to Quebecers’ needs.” Without adequate data, it is clear that this objective cannot be achieved.

We also believe the Commission must remind the Quebec government of its responsibilities regarding how it communicates its constitutional project. The government appears to have forgotten the spirit of the Act Respecting End-of-Life Care by emphasizing medical assistance in dying while neglecting to mention palliative care. This glaring imbalance between palliative care and MAiD in Quebec must end—it is not a “shared social value” across Quebec society.

Palliative care: navigating in the dark

After years of repeated warnings about the weakness of data on palliative care (“limited validity,” according to the most recent five-year report, and “lack of sufficient information,” according to the 2022–2023 report), the Commission has taken a further step by refusing to share data it deems non-representative. From the report:

The Commission reviewed the data submitted by institutions concerning the number of people who received palliative and end-of-life care (PEOLC). Unfortunately, for several years, it has noted that much data is missing, incomplete, or imprecise, or refers to very different contexts from one institution to another. The disparities observed appear to reflect both a lack of shared understanding of the information to be transmitted and difficulties in providing certain requested data. Consequently, the Commission considers that the data submitted are not representative of the real situation of palliative and end-of-life care in Quebec and that including them in this report could lead to misinterpretations. (p. 14 of the report)

We commend the Commission on end-of-life care for its integrity in choosing not to publish data that would not provide an accurate picture of palliative care in Quebec. This courageous decision should serve as a wake-up call for Minister Sonia Bélanger, who resumed her position on October 30th as Minister for Health and is responsible for this file. As the Commission’s five-year report reminded us:

“There are no management indicators or standardized tools for assessing the quality of palliative and end-of-life care services, how well they meet the needs of patients and families, or how efficiently the system operates. The Commission therefore cannot determine whether the needs of people who could benefit from such care are being met.”

We cannot continue to navigate blindly on such a critical issue.

According to those working in the field, there is no doubt that access to quality palliative care remains more difficult than access to medical assistance in dying (MAiD). Palliative care requires more time, as well as greater human and financial resources. In the spirit of the Act respecting end-of-life care, Quebecers should also have similar access to high-quality palliative care. Proper indicators should also clarify where we collectively stand on this matter. We welcome the Commission’s creation of an internal working group tasked with developing recommendations to strengthen access to palliative care. However, urgent and decisive action is needed—particularly to protect and improve access to home-based palliative care, which has been severely undermined by Bill 2 (see numerous testimonies in French here and here).

Media contact :
Jasmin Lemieux-Lefebvre, coordinator, Living with Dignity citizen network
www.vivredignite.org/en / info@vivredignite.org
438 931-1233

Canadian Physician sends Open Letter to the House of Lords (UK) Opposing Assisted Suicide.

Dr Paul Saba

As the United Kingdom’s House of Lords debates the legalization of medically assisted dying—commonly called MAID (Medical Assistance in Dying) in Canada—I want to warn the people of the United Kingdom not to go down this wrong and dangerous road that Canada has embarked on since 2016. 

The first reason not to legalize assisted suicide is that the eligibility for ending patients’ lives expands dramatically over time. This leads to unnecessary deaths for people who may have many years, if not decades, left to live. 

When Canada first legalized MAID in 2016, it was supposed to be for only a handful of terminally ill patients with just days to live. In 2016, there were 1,018 assisted deaths. By 2023, the number had increased to 15,343. From the inception of the law to the end of 2023, 60,301 Canadians had their lives ended by physician-assisted death. The numbers continue to rise each year. (Link) 

Québec, the province where I practise medicine, has the highest rate of euthanasia in both Canada and the world, at 7.6% of all deaths in the province. In 2024, the Commission sur les Soins de Fin de Vie—a government body that oversees end-of-life care—reported 6,058 euthanasia deaths between April 1, 2023 and March 31, 2024. (Link) 

The law was extended from those with terminal illnesses to those with chronic conditions and disabilities in 2021, following the passage of Bill C-7. Those with fragile health are also considered candidates for assisted dying. 

Starting in March 2027, those with mental illness will be eligible for physician-assisted death. I am strongly opposed to this expansion, as are many in the medical and psychiatric communities, who have raised concerns about the dangers of offering assisted suicide to vulnerable individuals with mental health challenges. This move has been highly controversial in Canada, with many experts warning about the risks of premature death among those who could otherwise recover or improve with treatment. 

As a physician, I sit on a review committee at one of Canada’s medical centres that assesses assisted deaths. The majority of the cases I have reviewed include people with medical conditions or disabilities, most with associated psychological and social factors that greatly influence their decision to request physician-assisted death. These factors include social isolation, feeling that they are a burden, loss of autonomy, and psychological distress. Based on my observations, physical pain was the least common reason. My experience is confirmed by Canada’s recent report on physician-assisted death. (Link) 

The State of Oregon was the first US state to legalise assisted suicide. In that state, the reasons for assisted suicide shows a similar pattern to Canada with loss of independence, wanting to control the time and manner of death, the fear of worsening pain or quality of life and the inability to care for themselves heading the list. (Link) 

Another reason not to go down this dangerous road is because of diagnostic errors. Physicians are human. When doctors give a patient a diagnosis, they can be wrong. In fact, errors in diagnosis for severe, life-threatening conditions may be as high as twenty percent in hospitalized patients. (Link) 

Several years ago, one of my patients, Jim (a pseudonym to protect his identity), came to me with a cough, thinking he had a cold. I ordered a chest x-ray. According to the radiologist’s report of the chest film, Jim appeared to have lung cancer. 

I sat down with Jim and said: 

“We need to do a scan right away. We need to get you to see a specialist. We need to do a bronchoscopy….” 

Jim responded: 

“Dr. Saba, I know you’re against assisted suicide, but you know what? I don’t necessarily agree with you. If I’m going to die, if my time is up….” 

I replied, 

“No, no. You have to go through the process because this is only a preliminary diagnosis. Even if it is lung cancer, it is treatable today. There are new treatments. It may not even be lung cancer.” 

I spoke to the radiologist who performed the lung scan, who said, 

“We’re not sure what it is. It appears to be lung cancer but it may be a lymphoma, which would be highly treatable.” 

Jim is an intelligent, well-informed man, an engineer, who thought he had a cold, then was told he might have cancer. He could have resigned himself to a medically assisted death before he even knew what we were dealing with, since Canadian law does not require that all diagnostic avenues be exhausted before a person is deemed eligible for MAID. Under current policy, a person can be eligible without undergoing every investigation necessary to confirm the diagnosis or rule out effective treatment. He could have given up hope while the situation was still filled with hope. The power to move people to give up is one of the dangerous and misleading aspects of medically assisted dying. 

However, I was able to get his attention and persuade him that the situation was hopeful and that he should get more tests and undergo treatment. The result? He called me in the summer of 2019 to thank me because there was no further evidence of disease, which is still the case today. He had finally been diagnosed with Hodgkin’s lymphoma, which is a condition that is highly curable with proper medical treatment. 

A Canadian study found that 13% of patients with a diagnosis of “lung cancer” who died by MAiD did not have a biopsy-proven diagnosis of lung cancer. Moreover, only a third of those diagnosed with advanced lung cancer underwent systemic treatments despite the availability of known effective treatments. (Link) 

This is what happens when the door is opened to assisted dying. Jim could have been another assisted dying fatality. I am a doctor who believes medicine must be grounded in solid science, in what research and experience teach us about how the body works and heals. 

Another reason not to go down the deadly road of assisted suicide is because it becomes an excuse for a faulty healthcare system lacking resources. Canada‘s publicly funded healthcare system lacks access to care for family physicians, specialists, investigative studies and has long waiting times for surgeries. In fact, Canada is considered one of the worst healthcare systems among OECD countries. (Link) 

Inversely, Canada has one of the fastest growing assisted dying programmes in the world. (Link) In contrast, palliative care for people seeking end-of-life care is not available for 70% of the population. The resources used for assisted dying should be rerouted to treat these patients. (Link) 

Canada like the United Kingdom has a publicly funded healthcare system. In Canada, assisted dying has become the default procedure for a healthcare system that has seriously failed to adequately care for its population. Similarly, Australia, which is given as an example for the British assisted suicide Bill, also has failed at providing quality palliative care. (Link) 

The conclusion—hope is one of the most powerful forces for good medical care. When I say hope is a powerful force for health, I mean that hope counsels us to patience, to seeing processes through, and to regarding every step as part of the great gift of being made for life. Assisted dying destroys that hope and leads people to giving up on life before their time. 

Dr. Paul Saba is a physician practicing family medicine in Lachine, Québec. He is a co-founder of the Physicians Alliance Against Assisted Suicide (https://collectifmedecins.org/en/about/) and is the author of the book Made to Live (madetolive.com) 1 514-886-3447 pauljsaba@gmail.com

Québec Medical Group requires physicians and nurse practitioners to refer for euthanasia.

Alex Schadenberg

Executive Director, Euthanasia Prevention Coalition

A memorandum from a Québec medical group reminds healthcare professionals of the obligation to leave their conscience "at the door" and refer patients for death by euthanasia (MAiD). The subject line reads "General reminder regarding requests for medical assistance in dying (MAiD)."

 

Canada legalized MAiD in June 2016 by creating an exception in the Criminal Code for homicide (murder).

An association of healthcare professionals in Montreal Québec sent a memorandum as a "general reminder" regarding requests for medical assistance in dying (MAID) to ensure that all healthcare professionals know that they are obligated to refer all patients who request death by euthanasia (MAiD). If the healthcare professional conscientiously objects the request must be sent to the Interdisciplinary Support Group (ISG). The memorandum states:

No healthcare professional can ignore a request for MAID. It is the responsibility of every professional to ensure that such a request is taken care of. As stipulated in sections 26 & 31 of the s-32.0001 - Act respecting end-of life care, any health or social services professional may complete the (contemporary) MAID request form when a person so requests.

Any physician or specialized nurse practitioner who receives a request for an MAID must notify the Interdisciplinary Support Group (ISG) and, if applicable, forward the request form to the ISG when he or she:

• refuses a request (based on the eligibility criteria recognized by the Act);
• refuses to assist a person in formulating an anticipated application (moral or religious conscientious objection) or in withdrawing such an application;
• refuses to carry out the required examination.

The ISG is to provide clinical, administrative and ethical support for end-of-life care. In particular, for the evaluation of a request or the administration of MAID, continuous palliative sedation and in the drafting of an anticipated MAID application (answering questions, coaching and mentoring by experts).

You can contact the MAID and ISG coordinator by e-mail: amm.comtl@ssss.gouv.qc.ca or at: 514-809-6174.

For more information, the CIUSSS intranet is regularly updated https://intranet.comtl.rtss.qc.ca/en/clinicalpractice/palliative-care-and-end-of-life-care/medical-assistance-in-dying-maid.

We remind you that no intimidation of anyone requesting information or an MAID, nor of the professionals involved, will be tolerated. Anyone witnessing such a situation should report it: employees should inform their superior, users and families should contact the Ombudsman.

Thank you for your cooperation,

For people outside of Canada, healthcare is a provincial jurisdiction, therefore each province will have different rules pertaining to referrals for euthanasia. 

 

When reading this memorandum, it is sadly not surprising that Québec has the highest euthanasia rate in the world.

 

More articles on this topic:

• Canada's euthanasia deaths continue to rise with approximately 16,500 euthanasia deaths in 2024 (Link).
• Québec shows the way with euthanasia in Canada (Link).
• Québec approves euthanasia by advance request (Link).

A thought-provoking overview of medical aid in dying in Québec

Press release was published by Vivre dans la Dignité on March 3, 2025.

Second analysis of the Five-year report of the Québec Commission on end-of-life care

Montreal, March 3, 2025 – After an earlier press release addressing the palliative care section in the “Rapport sur la situation des soins de fin de vie au Québec 2018-2023” (Report on the state of end-of-life care in Quebec 2018-2023), Living with Dignity (LWD) now focuses on the section pertaining to medical aid in dying (MAiD). This communication does not aim to summarize the Commission’s extensive work on end-of-life care but instead highlights key points that are important to the citizen network, which have not been widely covered in the media so far. The following quotes speak for themselves (quotes from the report have been translated by LWD).

Unprecedented revelation of the proportion of deaths by MAiD for each type of serious and incurable disease

“While the overall proportion of deaths by MAiD is 6.2% in 2022, this proportion varies greatly for each disease. For the most common cancers, the rates varied from 13.8% to 17.2%; for those with the most common neurological or neurodegenerative diseases (Parkinson’s disease, multiple sclerosis, amyotrophic lateral sclerosis), the rate varied from 24.5% to 41.9%…” (p. 26).

Fear that MAiD will replace “natural death” for some seniors

“However, some people, including some Commissioners, remain concerned that MAiD may replace “natural death” for elderly people who, faced with a progressive loss of autonomy, choose to apply for MAiD rather than live in conditions they consider intolerable. As the Commission has already reminded
providers in a Communiqué, old age, even when accompanied by a significant loss of autonomy, cannot be considered a serious and incurable disease that qualifies for MAiD.” (p. 62).

Reminder that various age-related conditions, such as frailty syndrome, are not eligible for MAiD in Quebec

“The differences between Quebec and the rest of Canada could be explained by a broader interpretation of the criterion of serious and incurable illness and the inclusion of serious and incurable conditions in the other provinces. This qualifies individuals aged 90 years and over with various conditions associated with old age, such as frailty syndrome, for MAiD. However, these conditions are not considered serious and incurable diseases for eligibility for MAiD in Quebec.” (p.56).

A delay of one day or less between the request and the administration of MAiD is rare, but it does exist

“A delay of one day or less between the request for and administration of MAiD was reported in 3.6% (514/14,417) of forms documenting administration of MAiD between April 1, 2018 and March 31, 2023.” (p. 41).

During the period studied, 1,138 people withdrew their request or changed their mind

“The main reasons for non-administration of the MAiD among people who were not assessed by a physician who had agreed to take charge of their request were as follows: the people died (50.0%), they withdrew their application (22.7%) or they did not meet the eligibility requirements (13.6%).” (p. 83).

Case studies of MAiD that were deemed invalid by the Commission were very enlightening

Numerous examples on pp. 70-76 concerning “age-related frailty, natural death trajectory with several minor illnesses, morbid obesity with minor co-morbidities, fibromyalgia, various symptoms without diagnosis”, etc.

Additional comments from Living with Dignity

Difference in the Definition of Slippery Slopes in MAiD

In the report, the Commission presents its definition of the term slippery slope: “without changing the eligibility criteria in the law, (an) increasingly liberal interpretation” allowing MAiD for individuals who would not have been eligible to receive it in the first place (p. 61).

Our definition of slippery slopes also encompasses the legislative changes that have led to MAiD “no longer being exceptional care” (p. 54). In this sense, it echoes the findings expressed by several guests in Episode 4 of ICI Radio-Canada‘s La mort libre podcast, “Les pentes glissantes de l’aide médicale à mourir” (The slippery slopes of medical aid in dying).

One year after an International meeting on end-of-life issues was held in Paris, LWD is still observing slippery slopes in each of the jurisdictions that have opened the way to one form or another, of euthanasia or assisted suicide. Whether one is for or against this gesture, which some present as an “individual right”, it is never without consequences for the family, caregivers and those forced to consider it.

LWD deplores the exponential increase in access to MAiD over the period studied (an average annual increase of 41%). This increase is not comparable to the rises observed elsewhere in the world.

Socio-demographic and socio-economic data to be studied in greater depth

Since its 5th Annual Report on Medical Aid in Dying in Canada, 2023, Health Canada has provided more socio-demographic data (e.g., p. 57 “A total of 9,619 people of the 15,343 who received MAiD responded to this question, the vast majority of whom (95.8%) identified as Caucasian (White).”).

The Commission is quick to address the indigenous and socio-cultural issue: “In the territories of indigenous communities, there are virtually no requests for MAiD, and none are reported by establishments in these regions. The same is true of other socio-cultural communities in certain territories.” (p.109).

It would be interesting to find out more about the reasons behind this difference in choice.

The addendum to the report (MAiD ethics in Quebec: reflections on a decade of deliberations) by Eugene Bereza and Véronique Fraser, also addresses the issue of socio-economic factors contributing to suffering. “Is it ethically acceptable that poverty, social isolation, refusal to go to a CHSLD or lack of access to care are factors that contribute significantly to a person’s subjective experience of intolerable suffering and lead to a request for MAiD?” (p. 122). LWD shares their concerns.

Large variations between the 32 institutions remain unexplained

“Variation from single to triple in institutions for palliative and end-of-life care rates and MAiD…” For continuous palliative sedation (CPS), there is a variation from single to quintuple” (p. 112).

According to the Commission, “We must refrain from drawing hasty conclusions about institutions based on variations in the rate of the three end-of-life care services. There is nothing in this report to suggest inter-regional or inter-institutional inequity.” It adds that “where there is more palliative and end-of-life care, there is also more CPS and more MAiD.”

As we pointed out in our first press release, we know very little about the type of palliative care offered (there is a significant difference between a purely pharmacological approach in the later stages vs. comprehensive palliative care earlier on).

Through its network of health professionals, LWD believes that Quebec’s “continuum of care” approach is detrimental to the development of palliative care. Variations, such as rates of access to medical aid in dying ranging from 10.4% (Lanaudière), 9.7% (Quebec), 7.5% (Eastern Townships), 5.2% (Outaouais) to 4.6% (Montreal) in 2022-2023 (see Table C2), should make us reflect on access to end-of-life services across the province. Like the Commission, we hope that the work of the Consortium interdisciplinaire de recherche sur l’aide médicale à mourir (CIRAMM) will contribute to this.

Media contact :
Jasmin Lemieux-Lefebvre
Coordinator, Living with Dignity citizen network
www.vivredignite.org/en

info@vivredignite.org
438 931-1233

Québec’s five-year Euthanasia Report (2018-2023) on the situation in end-of-life care.

Amy Hasbrouck

By Amy Hasbrouck
Director: Toujours Vivant - Not Dead Yet,

In April of 2019, Québec’s Commission on end-of-life care (or CSFV for Commission sur les soins de fin de vie) released a report (French only) on the situation of end-of-life care in the province from December, 2015 through March, 2018, which summarized the first two plus years of palliative care, Continuous Palliative Sedation (CPS) and euthanasia. 

You can find my analysis of that report on EPC’s Blog or the website of Toujours Vivant-Not Dead Yet. At the time, I identified several problems with “Palliative and end-of-life care” (PELC) as imagined, organized and provided in Québec. These include:

• People stuck in institutions are requesting and receiving euthanasia, but there’s not enough information to know how many.
• There’s not enough information (I’m detecting a theme here) to know how doctors determine whether a person has capacity to choose euthanasia, or whether the request is voluntary. 
• What information (apart from the person’s or their family’s assurances) do doctors use to determine capacity and voluntariness; 
• Do doctors consider the impact of psychological, social, economic and discrimination-related barriers when determining capacity and voluntariness of the request?
  

• Early identification and referral for palliative care is inadequate. There is not enough data to know how many people who need palliative care aren’t getting it.
• The data are inadequate to establish the timeliness and quality of palliative care services provided, and whether they meet the needs of the person and their loved ones. 
• There is not enough information to explain the wide variation in the number of euthanasia and continuous palliative sedation (CPS) between doctors, hospitals and regions. 
• Six percent of people who received CPS did not have signed consent forms in their files. 
• Six percent of people who received CPS were not getting palliative care; this information is missing on another 11% of those who had CPS. 
• Four percent (66 of 1,498) euthanasia did not conform to the law, either because the person was ineligible, or safeguards were flouted. 
• The medical model adopted by Québec for assisted death is reflected in the location where CPS and euthanasia are administered. Less than 3% of CPS were administered at home, while about 20% of euthanasia were provided in the person’s home. Most occurred in hospitals. 
• The numbers didn’t come out right (discrepancies continue).

On February 24, 2025, Québec’s CSFV released a five-year report, covering the period from April 1, 2018 through March 31, 2023. The report runs 127 pages, not including 30 pages of appendices (featuring statistics describing who did what to whom, when, where, why, and for how long). Suffice it to say that all of the problems I noted in the 2018 report are still featured in the 2023 report (including the numbers not coming out right). This is a lot of information to get through, so I’m going to break it up into shorter, topic-oriented chunks for easier mental digestion. This post will deal with the palliative care findings. I would also recommend a similar article from Vivre dans la dignité/Living with Dignity. All translations are mine in collaboration with Google.

Subsequent articles will focus on Continuous Palliative Sedation, euthanasia, the activities of the Commission, and issues affecting the future of euthanasia in Québec.

Palliative Care

In the 2018 Summary report we identified several problems relating to palliative care. We noted in our webcast that “[t]he Commission admits it doesn’t have data to prove that the gaps in palliative care services observed in a study published in 2000 still exist, but they’re pretty sure that’s the case.” Five years, and multiple plans, studies and consultations later, the Commission still lacks crucial information. The report shows:

• how many people receive palliative and end-of-life care each year
• how many people were getting palliative care when they requested and received euthanasia and CPS, 
• The percentage of people receiving palliative and end-of-life care in various settings.
  

The 2023 report does not show:

• What palliative care services are provided,
• The duration and quality of the services, 
• If the services met the needs of the people receiving them, their families and carers;
  

• How long was the delay between the request for services and when they are provided?
• How many people are eligible for, but did not receive palliative care? 
• What related services (e.g. income supports, housing assistance, self-directed personal assistance or home modifications for accessibility) could decrease the need/demand for euthanasia?

The discussion of palliative care on page 8 of the report shows the continuing ambivalence about who palliative care is meant for. Québec’s statute, health and social service system usually refer to “palliative and end-of-life care” (PELC) together, («soins palliatifs et de fin de vie» or SPFV) rather than palliative care alone. In so doing, Québec expresses a policy-level preference for limiting access to palliative care to people who are dying, thereby ignoring the needs of people with non-terminal disabilities and chronic conditions who could benefit from pain management and other services. Though the five-year report does pay lip service to expanding access to palliative care to people with “chronic illness with a limited prognosis.” Section 3.3 of the report (on pages 13-14) mentions an estimated 40,000 people who might not be getting the PELC they need). It’s not clear whether this group includes people who need pain management or other supports, but whose conditions are not likely to cause death, i.e. disabled people.

The association between palliative care and death may be a factor in a decrease in the number of people receiving palliative care since the 2015-2018 report. On page 44 of the 2018-2023 report, the Commission notes that: “Nearly 68% of people who asked for MAiD were receiving palliative care when they made the request, and 82% received it between the request and administration of MAiD.” This represents a DECREASE from the earlier study, where 80% of those asking to die were receiving palliative care when they made the request, and 89% were getting it when they were euthanized. The reason for the decrease is unclear.

The Québec statute’s end-of-life eligibility requirement was struck down in the Truchon court decision in 2019, yet the expansion of access to death has not been accompanied by greater access to services people need to live. As long as “Palliative and end-of-life care” forces a connection between “life-ending” and pain relief for people with disabilities and chronic conditions, the scope of the services offered will be inadequate to prevent disabled people from being forced to “choose” death.

Problems with inadequate data as to availability and quality of services that were identified in the first summary report (2015-2018) persisted in the new report, due in part to:

• Lack of standardization in codes for palliative care services between facilities (p. 12)
• People who were eligible for, and needed palliative care, but did not receive it, are not counted.
• People who were eligible for, and needed palliative care, received delayed referrals.

“Some experts … expressed concern that difficulties in accessing PELC could prompt some people to request MAiD to relieve suffering that could have been alleviated with [palliative and end of life care]” (p. 13).

Also on page 13, the report points to problems related to palliative care training

• “It appears that providers and care teams working in different care settings are not sufficiently trained to provide quality basic palliative care or to identify early people who could benefit from it.
• “The basic concepts of palliative care taught in professional curricula and continuing education offered in palliative care are insufficient. 
• “The shortage of qualified workers weakens and compromises the provision of quality palliative care and the maintenance of skills in PELC. 
• Psychosocial resources are also insufficient to meet the needs of people and their loved ones for support, assistance and respite. 
• There are no management indicators or standardized tools to assess 
• the quality of care and services in PELC, 
• the response to the needs of people and their loved ones, and 
• to examine the efficiency of the system.

Palliative care provision moved away from the home and toward hospitals, peaking at 38.6% in 2019. Despite the spike in home care during the pandemic (up to 44%, see figure 3.4 on p. 11) there was also an increase in palliative care in nursing homes at that time. Before the pandemic, home-based care was at or below 40%. The remainder was provided in nursing homes and hospice.

Palliative Care

• The Commission doesn’t have the data necessary to say:
• how many people that need palliative care aren’t getting it, or 
• the duration, quality, or suitability of the care.
  

• The report focuses on palliative care as an option only for people at the end of life.
• There’s no discussion of other kinds of support than palliative care to prevent requests for euthanasia; 
• how many people who need SDPA services to live at home aren’t getting them, or 
• For those who are getting in-home supports, the duration, quality, or appropriateness of palliative care.
  

Problems with voluntariness & consent for euthanasia

• We don’t know how doctors decide if a person is subject to abuse, coercion or other “external pressure” to request euthanasia,
• whether psycho-social, economic and discrimination-related factors are taken into account, 
• No information about assessment for coercion and abuse
  

• No information about doctors’ disability bias.

Palliative care

• Setting where palliative care was provided

2015-2018 - Home 47%, Hospital 31%, Nursing home 13%, Hospice 9%
2018-2023 - Home 42%, Hospital 37%, Nursing home 13%, Hospice 9%

Highlights of 2018-2023 report

• Overall
• Doesn’t give the totals of CPS or MAiD since the program began
  

• Obvious findings:
• The number of euthanasia and CPS are increasing. 
• Some doctors, hospitals, and regions provide more palliative care, CPS, and euthanasia than others. 
• Most of the people who die by euthanasia and CPS are over 60 years old and have cancer.
  

Palliative Care

• Use of SPFV Highlights the forced connection between “life-ending” and pain relief for chronic conditions.
• There are three types of people who could benefit from palliative care 
• People with terminal illness who die 
• People with chronic illness and disabilities who die (40,000) 
• People with chronic illnesses and disabilities who don’t die
  

• Only refers to palliative care at the end of life (SPFV p. 8)
• People with “life-threatening” prognoses (doesn’t count disabled) 
• “Relieve suffering without hastening or delaying death” p. 8
  

• Doesn’t talk about management of chronic pain.

Palliative care

• Disability supports, such as SDPA and access modifications, are not thoroughly discussed.
• Same problems with inadequate data as to availability and quality of services, 
• Problems caused by:
  
• Lack of standardization in codes for palliative care services between facilities (p. 12) 
• People who were eligible for, and needed palliative care, but did not receive it, are not counted. 
• People who were eligible for, and needed palliative care, received delayed referrals. 
• “Some experts and respondents to the questionnaire expressed concern that difficulties in accessing SPFV could prompt some people to request MAiD to relieve suffering that could have been alleviated with SPFV.” (P. 13)
• Especially for people who don’t have cancer.
  

• despite various studies and plans.
• The 2015-2020 Development Plan for Palliative and End-of-Life Care.
  
• The guidelines defined in the report of the national working group for equitable access to quality palliative and end-of-life care.
  
• The priorities and strategic measures presented in the 2020-2025 Action Plan For equitable access to quality palliative and end-of-life care. 
• Spring, 2023 consultation with 15 providers and experts in palliative care.
  

• Access to quality palliative care necessarily requires adequate training of providers. (p. 13)
• It appears that providers and care teams working in different care settings are not sufficiently trained to provide quality basic palliative care or to identify early people who could benefit from it. 
• It appears that providers and care teams working in different care settings are not sufficiently trained to provide quality basic palliative care or to promptly identify people who could benefit from it. 
• The basic concepts of palliative care taught in professional curricula and continuing education offered in palliative care are insufficient. 
• The shortage of qualified workers weakens and compromises the provision of quality palliative care and the maintenance of skills in SPFV. 
• Psycho-social resources are also insufficient to meet the needs for support, assistance and respite of individuals and their loved ones. 
• There are no indicators or standardized tools for assessing: 
• the quality of care and services provided, 
• the satisfaction of those receiving care and their loved ones, and 
• to provide an overview of the efficiency of the system.
  

• Public awareness about palliative care is inadequate
• “The vast majority of Quebecers will be supported at the end of their lives and will receive palliative care. Approximately 3% of them will receive a CPS and 7% MAID as end-of-life care.” For a total of nearly 10% (P. 8)

2015-2018 - Home 47%, Hospital 31%, Nursing home 13%, Hospice 9%

2018-2023 - Home 42%, Hospital 37%, Nursing home 13%, Hospice 9%

• Note decrease in home-based services, increase in hospital-provided services
• Despite home-care spike during the pandemic (fig. 3.4, p. 11) 
• In 2018 and 2019, home-based care was at or below 40%
  

Continuous Palliative Sedation (CPS)

• Of people who received CPS,
• 83% were receiving palliative care 
• 6% were not receiving palliative care 
• In 11% of cases, there was no information about whether they were getting palliative care.
  

• Rate of CPS increased from 1.8% in 2018-9 to 2.5% in 2022-3
• As a proportion of deaths in the province 
• 2015-2018 – low of .89% high of 1.37% 
• 2018-2023 – low of 1.8% high of 2.6%
  

• Consent forms properly filled out
• 94% 2015-2018, 95% 2019-2023. 
• Clarifications (but no numbers) were provided regarding certain cases in which the consent form was not signed, including: 
• the form was attached to the person’s file but was not signed; 
• the form was not attached to the file or to the documents sent to the CMDP, so it is not known whether it was signed; 
• verbal consent from the person or family replaced written consent; 
• for a person unable to consent to care, the form was not signed because the person’s representative was absent, due to special situations, such as the pandemic context.
  

• Psychological / existential distress = 58%;
• Physical pain = 28%; 
• Difficulty breathing = 25%; 
• Delirium and agitation = 20%.

Settings where CPS was administered

2015 - 2018 Home 4%, Hospital 58%, Nursing home 10%, Hospice 27%, Unspecified 1%.

2018 - 2023 Home 3.6%, Hospital 58.9%, Nursing home 9.2%, Hospice 28.3%, Unspecified --

Symptoms that justified CPS than about the kind of suffering that lead to requests for euthanasia:

Psychological or existential distress    2015-18 - 54%, 2019-23 - 59.4%

Intractable, intolerable pain                 2015-18 - 28%, 2019-23 - 32.9%

Progressive, uncontrollable dyspnea  2015-18 - 25%, 2019-23 - 25.5%

Agitated delirium                                    2015-18 - 20%, 2019-23 - 20.5%

Repeated respiratory distress               2015-18 - 16%, 2019-23 - 13.2%

Intractable nausea and vomiting        2015-18 - N/A, 2019-23 - 7.4%

Convulsions                                            2015 - 18 - N/A, 2019-23 - 1.5%

Uncontrolled hemorrage/bleeding    2015-18 - N/A, 2019-23 - 1.5%

Other (includes cachexia, dysphagia, fatigue/frailty)

                                                                   2015-18 - N/A, 2019-23 - 17.9%

Provided consent via approved form 2015-18 - 94%, 2019-23 - 95%

• A minority of CPS and euthanasia were administered in the person’s home.
• Less than 3% of CPS 
• about 20% of euthanasia were provided in the person’s home.
  

MAiD administered

• Total administered 2018 report = 1,632
• Total administered 2023 report = 14,417
• Total of both reports (2015-2023) = 16,049
  

• Four percent (66 of 1,498) euthanasia did not conform to the law
• 11 people were not eligible 
• In 55 cases, doctors failed to comply with safeguards.
  

MAiD not administered

• The data as transmitted by the institutions to the Commission do not allow us to know what is the situation regarding real access to palliative care in the network and the quality of care offered, in particular to know whether needs are actually met and what are the obstacles to accessing quality palliative care in a timely manner. 
• In order to partially fill this information gap, in spring 2023, the Commission consulted organizations and experts involved in the organization and delivery of SPFVs. The analysis of the consultations made it possible to identify a certain number of elements which, beyond the figures, provide a better idea of ​​the current situation of SPFVs and the issues associated with them. These findings were endorsed by the Commission.

- Timely access is still a major issue. Delays and inequity of access exist throughout Quebec. 

- Better access with a view to continuity of care requires better coordination of care and services offered in a given territory, particularly between institutions, palliative care homes, private clinics and volunteer organizations in order to ensure fluidity in the provision of palliative care and to meet the needs that may arise at various stages of the care trajectory. 

- Early screening and referral of people who could benefit from palliative care is a challenge. Indeed, many stakeholders likely to make timely referrals are not adequately trained to identify people who could benefit from palliative care, the relevance of which does not only arise at the end of life, but well before.

- Better information for the general population and health professionals, as well as a better understanding of palliative care, must be on the agenda if we want to improve the supply of palliative care services, access to this care, and its quality. 

 • In the opinion of many, there is very little reliable data on PFS and the available data is fragmentary. There is no universal coding system to accurately identify people who have benefited from PFS. Thus, drawing up an accurate overall picture is difficult. 

 • Although the INSPQ has estimated the number of people who could benefit from palliative care annually, this estimate is very fragmentary, because it does not specify the type and intensity of PFS required. More detailed studies are essential in order to plan the supply of PFS care and services that will meet the needs of Quebecers.

p. 14: “The data as transmitted by the institutions to the Commission do not allow us to know the true degree of access to palliative care in the network and the quality of care offered; in particular to know if the needs are actually met and what are the obstacles to accessing quality palliative care in a timely manner.” Or “do not make it possible to ascertain the true level of access to palliative care in the network or the quality of the care provided, in particular whether needs are effectively met and what the obstacles are to accessing timely, high-quality palliative care.”

• In order to partially fill this information gap, the Commission consulted organizations and experts involved in the organization and delivery of SPFV in the spring of 2023.” The analysis pointed to problems beyond the figures.

- Timely access is still a major issue. Delays and inequity of access exist throughout Quebec.

- Better access with a view to continuity of care requires better coordination of care and services offered in a given territory, particularly between institutions, palliative care homes, private clinics and volunteer organizations in order to ensure fluidity in the provision of palliative care and to meet the needs that may arise at various stages of the care trajectory.

- Early screening and referral of people who could benefit from palliative care is a challenge. Indeed, many stakeholders likely to make timely referrals are not adequately trained to identify people who could benefit from palliative care, the relevance of which does not only arise at the end of life, but well before.

- Better information for the general population and health professionals as well as a better understanding of palliative care must be on the agenda if we want to improve the supply of palliative care services, access to this care and its quality.

• In the opinion of many, there is very little reliable data on PFS and the available data is fragmentary. There is no universal coding system to accurately identify people who have benefited from PFS. Thus, drawing up an accurate overall picture is difficult.

• Although the INSPQ has estimated the number of people who could benefit from palliative care annually, this estimate is very fragmentary, because it does not specify the type and intensity of PFS required. More detailed studies are essential in order to plan the provision of PFS care and services that will meet the needs of Quebecers.

Palliative care before euthanasia p. 44: “Nearly 68% of those who asked for MAiD were receiving palliative care when they made the request and 82% received it between the request and administration of MAiD. These figures are lower than those reported in the Commission’s 2015-2018 triennial report (80% and 89%, respectively).” 

Previous reports by Amy Hasbrouck:

• Québec euthanasia deaths increase by 51% in 2021 - 22 Annual report. A discrepancy of 289 deaths (Link). 
• Québec 2021 Annual euthanasia report. Euthanasia deaths increase by 37%. Unreported deaths continue (Link).