Medical Assistance in Dying committee  Thank you very much. I practise internal medicine and geriatrics, and most of my work is with older adults or people dealing with geriatric syndromes such as frailty and dementia. I often care for patients who are making important and potentially life-limiting decisions and regularly assess patients' capacity for decision-making in these contexts.

Medical Assistance in Dying committee  Yes. This provides an opportunity to advocate action on the national dementia strategy. Just as we talk about the need for strengthening mental health care in the context of MAID for mental disorders and we worry about people seeking MAID for physical conditions when palliative symptom management is suboptimal, and we appropriately see this as a time to call for strengthening those services, we must also see that this issue of advance requests for MAID is intimately tied with the quality of dementia care in Canada.

Medical Assistance in Dying committee  Sure. Thank you for the question. Really, you can think about these decisions as happening at every stage along somebody's entire journey. Even people who have no symptoms at all may decide that they can justify, for good reasons, that they do not want to have testing, screening, examinations or X-rays.

Medical Assistance in Dying committee  Yes, they are, certainly.

Medical Assistance in Dying committee  Part of the reason we do that is that we want it to be based on what they would want. That's why we listen to an advance directive preferentially to just deciding what's in their best interest. Of course, the ideal advance directive might include naming a substitute decision-maker who can help walk through the different options that are presented in front of them—somebody who's trusted and chosen by the person.

Medical Assistance in Dying committee  I think the detail would be really important. Again, my examples were not just not recognizing the family. I want to understand really where that request is coming from, what you mean by that, and give people enough education around creating these advance requests that they understand what elements of the symptoms of their condition would be the troublesome ones to them.

Medical Assistance in Dying committee  Sorry; I was relying on my French. I'm mostly following. You said les dérives. What do you mean by that?

Medical Assistance in Dying committee  In most of my discussions with people living with dementia, they're expressing indignation, essentially, that they are not taken seriously with regard to their own wishes, because perhaps a future self is valued more than their current self. Of course, there could be slippery-slope arguments, such that if somebody makes a request, it could be taken too far, or that somebody who's thought to be a trusted decision-maker perhaps makes a decision that is in their own self-interest as opposed to the person's interest, or perhaps they are are constrained, despite what we hope, by economic or social circumstances.

Medical Assistance in Dying committee  Yes.

Medical Assistance in Dying committee  Yes.

Medical Assistance in Dying committee  Yes, I think so, not having done it yet. I do think so, because it would be based on the same principles of the person understanding the facts, applying those facts to their situation, reasoning pros and cons, manipulating that information and then considering alternatives and being able to communicate that choice, and making sure that it's being done without coercion.

Medical Assistance in Dying committee  I totally agree that the diagnosis does not necessarily mean incapacity. That's a separate question and would happen later. I would add the important point that in some places, unfortunately, we lack access to diagnosis. Some people, unfortunately, get a diagnosis quite late in their journey, even if they were trying to get it earlier.

Medical Assistance in Dying committee  That's an interesting point. Yes, if you require a diagnosis, it relies on the diagnosis having been made early enough, and all of the education that would go along with making these decisions being done early enough, before the lack of capacity occurs.