London, Ont. physician who met patient at coffee shop to discuss MAID reprimanded

A doctor holds a patient's hand in this this up generic image. (Source: Getty)

A London physician has been reprimanded after two breaches of patient care stemming from incidents involving him meeting a patient outside a coffee shop to discuss MAID and improperly providing MAID to a second patient.

According to two reports, two separate complainants contacted the College of Physicians and Surgeons of Ontario to express concerns about the patients’ care and the conduct of the physician while providing Medical Assistance in Dying (MAID).

The reports do not mention when the incidents occurred.

Patient #1

The college says Dr. James MacLean, a physician based in London, had a patient in his care with a medical history of inflammatory bowel disease, associated surgeries, and mental health concerns, and as a result, applied for MAID.

After the application, the patient underwent assessments of his eligibility, completed by MacLean and a nurse.

The college says MacLean “conducted his assessment of the patient outside a coffee shop.”

The patient was deemed eligible for MAID under track two, which is designed for people “whose death is not reasonably foreseeable, but who suffer intolerably from a grievous and irremediable medical condition.”

At the patient’s request, MacLean drove the patient to the MAID provision location before providing MAID to the patient.

In the case of patient #1, the Inquiries, Complaints and Reports Committee expressed concern with MacLean’s approach to the assessment process, “specifically discussing sensitive MAID-related matters in an informal public setting,” adding that other locations were not meaningfully explored at the time.

“In the committee’s view, this reflected a lack of the level of formality and care expected when assessing requests for MAID. The committee was also troubled by the respondent’s communications and degree of personal involvement with the patient.”

The committee goes on to say that the quantity and nature of MacLean’s text messaging with the patient “went beyond” what was reasonably required to support the MAID assessment and arrange MAID provision.

The committee also highlighted MacLean’s decision to personally transport the patient to the MAID location, which further raised concerns about professional boundaries.

“Taken together, these actions created a risk that [MacLean’s] involvement could be perceived as influencing the patient,” adding that it represented a significant power imbalance between doctor and patient, representing a further risk when a patient has mental health or substance abuse issues, the committee concluded in its report.

Patient #2

According to a second report, the college says MacLean had a patient in his care and determined they were eligible for MAID following primary and secondary assessments. The patient completed a waiver of final consent to be used in the event of a loss of capacity.

Prior to the date of the MAID provision, the patient lost capacity and was unresponsive. The college says MacLean was asked to attend the patient’s home and provide MAID in accordance with the final consent waiver.

The college says MacLean ordered a MAID medication kit for the patient; however, the kit was not ready when he went to the pharmacy to pick it up. As a result, MacLean visited the patient’s home with a previously acquired MAID medication kit.

MacLean administered the anesthetic propofol, but did not administer a neuromuscular-blocking medication, which is typically used as “he was unable to locate it in his briefcase.”

The college says shortly afterward, MacLean pronounced the patient’s death after being unable to hear a heartbeat. After leaving the patient’s home however “the patient resumed spontaneous breathing.”

MacLean returned to the patient’s home, and once he observed signs of cardiac and respiratory activity, he administered additional medication including the neuromuscular blocking agent and again pronounced the patient’s death.

In the case of patient #2, the committee says MacLean “believes the stress of the situation, including the last‑minute and urgent request for his attendance and the substantial number of people present with significant tension amongst them, contributed to initial failed provision of MAID.”

The committee expressed concern that some aspects of care and conduct offered by MacLean for the patient “departed from these expectations.”

The committee cites not adequately preparing for the provision of MAID, not administering the full medication protocol as intended, and placing undue emphasis on urgency over adherence to established processes.

“Taken together, these issues raised serious concerns about [MacLean’s] judgment, adherence to procedure, and patient safety in the provision of MAID,” the report reads.

In addition, the initial complainant expressed concerns about MacLean’s professionalism and communication, including that although the two parties had differing recollections as to how the events unfolded, “information provided by both parties supported that [MacLean] was not communicating effectively or professionally with the patient’s relatives.”

The college’s rulings and reprimand

The college says that while the legal framework has changed over time, MAID remains “a highly regulated area of medical practice with well-defined expectations” and therefore “physicians are expected to follow these requirements carefully and consistently in order to provide appropriate care and to maintain public trust in the profession.”

In both cases, the college says MacLean “demonstrated some appropriate reflection” in his responses to both complaints and “committed to implementing certain changes,” but express concern over his lack of sufficient insight into how certain aspects of his care and conduct required further improvement.

“The committee therefore concluded that [MacLean] would benefit from a discussion with his peers and that it was appropriate to caution [MacLean] with respect to his MAID practice,” the report concludes.

As a result of the investigations, MacLean was placed under three months of moderate supervision, three months of low supervision, and needs to review multiple MAID charts with the college supervisor.

MacLean is still permitted to practice medicine while under supervision.