Redefining the practice of medicine
Euthanasia in Quebec
An Act Respecting End-of-Life Care (June, 2014)
Sean Murphy*
Appendix "A": Health Care Delivery in Quebec
A1.1 An Act Respecting Health Services and Social Services provides the
administrative framework for the delivery of health care in Quebec, outlines
principles that inform the system and sets out the rights and obligations of
various parties. It supported by An Act respecting the Health and Social
Services Ombudsman.
A1.2 The Professional Code establishes the structure of professions in
the province (called "orders") including the health care professions. It
also establishes the Office des professions du Québec, consisting of five
government appointees. Among other things, the Office has the power to
supervise the professions to ensure that they conform to the requirements of
the Professional Code.1
A1.3 Subject to the Professional Code, separate statutes govern
pharmacists,2 nurses,3 physicians4 and midwives.5
A2.1 A health and social services agency established by the government in
each region of the province is designated as the state agency responsible
for responsible for the delivery and coordination of health care in the
region.6 Every agency must establish a public health department, and may
request the Minister for Social Services and Youth Protection to appoint a
public health director.7
A3.1 Regional complaints commissioners are answerable to the regional
health agency that appoint them but are expected to act independently to
enforce "user rights" and respond diligently by investigating "user
complaints."8 They are to promote and explain the complaint process to people
in the region9 and encourage and support people in formulating complaints.10
A4.1 In each region, the government has established a nursing commission.11
A nursing commission is responsible to the board of directors of the
regional health and social services agency and provides advice about nursing
care, staffing and other issues.12 The government has also established a
multidisciplinary commission in each region, with analogous functions.13
A5.1 In addition to regional health and social service agencies, "local
health and social services networks"14 have been established "to foster a
greater sense of responsibility among all the health and social service
providers in the network to ensure that the people in the network's
territory have continuous access to a broad range of general, specialized
and superspecialized health services and social services."15 These networks
are coordinated by local authorities operating local community service
centres, residential and long-term care centres or general and specialized
hospital centres.16 Local authorities have numerous responsibilities,17 among
which is working with other elements of the health care bureaucracy to
"create conditions that foster accessibility, continuity and networking of
general medical services, focusing in particular on accessibility."18
A6.1 Incorporated non-profit community organizations governed by boards
of directors may engage " in activities related to the field of health and
social services,"19 including (if authorized by the Minister) the provision of
abortion.20 Community organizations may receive subsidies from regional health
and social services agencies,21 or from the Quebec government,22 but remain free
to define their "orientations, policies and approaches."23 Subsidized
community organizations must send annual activity and financial reports to
the subsidizing authorities.24 They may also agree to be subject to the
regional complaint process (see Appendix "B").25
A7.1 Private nursing homes, private institutions that operate residential
and long term care centres and community organizations may apply to the
regional health and social services agency for accreditation.26 Accreditation
may be granted by the Minister only if they conform to the Minister's
accreditation requirements.27 Accreditation may be granted temporarily or for
specified periods; continued accreditation depends upon continued compliance
with the Act and the conditions set by the Minister.28 Regional health and
social service agencies may grant a financial allowance only to accredited
persons.29
A8.1 A private seniors' residence is a facility for persons at least 65
years of age that provides residential accommodation and at least two
services identified by regulation. Every regional health and social services
agency must maintain a register of private seniors' residences in its
jurisdiction.30 All such residences are subject to regulation and inspection
and require certificates of compliance in order to operate.31
A9.1 A specialized medical centre may be opened only by physicians. It
must be governed by a board, the majority of whom must be physicians
practising in the centre32 and supervised by a medical director appointed from
among them.33 Specialized medical centres may provide "services necessary for
a hip or knee replacement, a cataract extraction and intraocular lens
implantation" and other specialized medical treatment authorized by the
government through regulation.34
A10.1 Health care is provided in five kinds of facilities: a local
community service centres, hospital centres, child and youth protection
centres, residential and long-term care centres and rehabilitation centres.35
A11.1 As a general rule, any person or partnership who carries on
"activities inherent in the mission" of one of these five kinds of centres
is considered to be an "institution."36 However, there are some exceptions,
including persons or partnerships operating private health facilities37 and
some religious or teaching institutions that operate infirmaries for their
personnel, members or followers.38
A11.2 Institutions are public or private.39 Institutions are public if they
are non-profit corporations, or if they are incorporated or are formed as a
result of amalgamation or conversion under the Act Respecting Health
Services and Social Services.40
A11.3 Private institutions are unincorporated, or profit-making
corporations, or non-profit corporations providing some kinds of health care
for fewer than 20 patients.41
A12.1 Public institutions are governed by boards of directors42 constituted43
and functioning44 in accordance with the Act. Each board must form governance,
ethics, audit and watchdog committees45 and appoint a local service quality
and complaints commissioner.46 Boards of directors of private institutions
have the same functions and responsibilities.47
A12.2 Presumably under the auspices of the board of directors, every
institution "must adopt a code of ethics which shall set out the rights of
the users and the practices and conduct expected, with respect to the users,
from the employees, the trainees, including medical residents, and the
professionals practising in a centre operated by the institution" and
provide a copy of it to every institutional "user" upon request.48
A13.1 Local complaints commissioners are answerable to the institutional
boards that appoint them but are expected to act independently to enforce
"user rights" and respond diligently by investigating "user complaints."49
They are to promote and explain the complaint process to people served by an
institution50 and encourage and support them in formulating complaints.51
A14.1 Executive directors, appointed by and responsible to boards of
directors, are responsible for day-to-day operations of institutions.52
A15.1 Every local authority in charge of a health and social services
network and every institution operating a hospital must appoint a physician
as director of professional services. Other institutions may appoint
directors of professional services, but are not required to do so.53
A15.2 Acting under the authority of the executive director, the director
of professional services coordinates the professional and scientific
activities of an institution.54 In particular, they direct and supervise
clinical department heads55 and councils of physicians, dentists and
pharmacists.56
A16.1 Every local authority in charge of a health and social services
network and every institution operating a hospital must appoint a nurse as
director of nursing care. Alternatively, the executive director may
designate a nurse to take charge of nursing. Other institutions may appoint
directors of nursing care, but are not required to do so.57 Acting under the
authority of the executive director, directors of nursing care supervise and
monitor nursing care.58
A17.1 Every institution operating a local community service centre in
which midwifery is practised must appoint midwife as midwifery services
coordinator. Coordinators must define standards of care, and supervise
midwives and coordinate the provision of midwifery services.59
A18.1 An institutional board of directors must appoint a Medical
Examiner, either for each of the facilities it operates, or as Medical
Examiner for all of them. A Director of Professional Services may be so
designated. Medical Examiners are responsible to the board of directors for
the investigation of complaints involving physicians, dentists or
pharmacists, or a medical resident.60
A19.1 Every public institution with a centre employing at least five
physicians, dentists or pharmacists must form a council of that includes all
of them. Boards of directors that operate more than one institution may form
a single council composed of the practitioners in all of the institutions.61
Councils of physicians, dentists and pharmacists are, among other things,
responsible for assessing and maintaining professional standards62 and making
recommendations about medical care and dental care and the use of medicines.63
A19.2 Councils of physicians, dentists and pharmacists can give opinions
about disciplinary measures against physicians, pharmacists or dentists,64 and
make recommendations about obligations associated with privileges granted to
physicians or dentists, especially with respect to participation in clinical
activities.65
A19.3 Every public institution with a centre employing at least five
nurses must form a council of nurses that includes all of them. Boards of
directors that operate more than one institution may form a single council
composed of the practitioners in all of the institutions.66
An executive
committee of at least four nurses exercises the responsibilities of the
council.67 Councils of nurses are responsible for assessing and maintaining
the quality of nursing care68 and making recommendations about it.69 A council
of nurses is also responsible for forming a committee to perform the
council's functions with respect to nursing assistants.70
A19.4 Every public institution that has contracted with at least five
midwives must form a council of midwives consisting of all of them,71 unless
the midwives and the council of physicians, dentists and pharmacists agree
that the latter should exercise the function of a council of midwives.72 When
a council of midwives is formed, an executive committee comprised of at
three midwives and the executive director of the institution exercises the
powers of the council.73 These include
monitoring and assessing the work of the midwives,74
recommending standards of care75 and
"obligations to be attached to the practice of midwifery,"76
and confirming the qualifications of midwife applicants.77
A19.5 Multidisciplinary councils must be formed in every public
institution, consisting of employees (except physicians, dentists,
pharmacists and nurses) who hold college diplomas or university degrees who
perform functions in their field of expertise directly related to nursing
assistance, health services, social services, and research or teaching.78
Multidisciplinary councils assessing and improving the quality of the
professional activities of their members, and making recommendations
concerning them.79
A20.1 Every clinical department in a hospital must be headed by a
physician, pharmacist, dentist or clinical biochemist.80 Clinical department
heads are primarily responsible for coordinating and supervising
professional activities81 and the allocation and use of resources in each
department.82 They may also offer opinions about the granting or maintenance
of professional status and privileges and the obligations attached to them.83
A21.1 Every public and private institution must establish and provide
funds for a Users' Committee, consisting of at least five members elected by
users of institutional facilities84 for terms not exceeding three years.85 Among
their responsibilities, Users' Committees are to "inform users of their
rights and obligations,"86 defend the rights and interests of users,87 and
accompany and assist users in making complaints.88
A22.1 The office of Health Services Ombudsman is exercised by a Deputy
Public Protector appointed under the Public Protector Act. The Ombudsman is
to ensure that people seeking heath care are respected and that their rights
are enforced.89
Notes:
1.
Professional Code (R.S.Q. c C-26) Sections 3-16.8 (Accessed
2014-07-27)
2.
Pharmacy Act (R.S.Q. c-P10) (Accessed 2014-07-27)
3.
Nurses Act (R.S.Q. c I-8) (Accessed 2014-07-27)
4.
Medical Act (R.S.Q. c M-9) (Accessed 2014-07-27)
5. Midwives
Act (R.S.Q.. c S-0.1) (Accessed 2014-07-27)
6.
An Act Respecting Health Services and Social Services, (R.S.Q.
Chapter S-4.2) (Hereinafter "ARHS&SS) Sections 339-342.1. (Accessed
2014-07-27)
7.
ARHS&SS, Sections 371-372. (Accessed 2014-07-27)
8.
ARHS&SS, Section 66. (Accessed 2014-07-27)
9.
ARHS&SS, Section 66(2). (Accessed 2014-07-27)
10.
ARHS&SS, Section 66(3). (Accessed 2014-07-27)
11.
ARHS&SS, Sections 370.1. (Accessed 2014-07-27)
12.
ARHS&SS, Section 370.3. (Accessed 2014-07-27)
13.
ARHS&SS, Sections 370.5-370.7. (Accessed 2014-07-27)
14.
ARHS&SS, Section 99.2. (Accessed 2014-07-27)
15.
ARHS&SS, Section 99.3. (Accessed 2014-07-27)
16.
ARHS&SS, Section 99.4. (Accessed 2014-07-27)
17.
ARHS&SS, Sections 99.5-99.8. (Accessed 2014-07-27)
18.
ARHS&SS, Section 99.9.7. (Accessed 2014-07-27)
19.
ARHS&SS, Section 334. (Accessed 2014-07-27)
20.
ARHS&SS, Section 338.1. (Accessed 2014-07-27)
21.
ARHS&SS, Section 336. (Accessed 2014-07-27)
22.
ARHS&SS, Section 337. (Accessed 2014-07-27)
23.
ARHS&SS, Section 335. (Accessed 2014-07-27)
24.
ARHS&SS, Section 338. (Accessed 2014-07-27)
25.
ARHS&SS, Sections 76.6, 76.7. (Accessed 2014-07-27)
26.
ARHS&SS, Section 457. (Accessed 2014-07-27)
27.
ARHS&SS, Section 456. (Accessed 2014-07-27)
28.
ARHS&SS, Section 458. (Accessed 2014-07-27)
29.
ARHS&SS, Section 454, 455. (Accessed 2014-07-27)
30.
ARHS&SS, Section 346.0.1. (Accessed 2014-07-27)
31.
ARHS&SS, Sections 346.0.2, 346.0.4, 346.0.8. (Accessed
2014-07-27)
32.
ARHS&SS, Section 333.2. (Accessed 2014-07-27)
33.
ARHS&SS, Section 333.5. (Accessed 2014-07-27)
34.
ARHS&SS, Section 333.1. (Accessed 2014-07-27)
35.
ARHS&SS, Sections 79. (Accessed 2014-07-27)
36.
ARHS&SS, Sections 94. (Accessed 2014-07-27)
37.
ARHS&SS, Sections 95. (Accessed 2014-07-27)
38.
ARHS&SS, Sections 96. (Accessed 2014-07-27)
39.
ARHS&SS, Sections 97. (Accessed 2014-07-27)
40.
ARHS&SS, Sections 98. (Accessed 2014-07-27)
41.
ARHS&SS, Sections 99. (Accessed 2014-07-27)
42.
ARHS&SS, Sections 119-128.1. (Accessed 2014-07-27)
43.
ARHS&SS, Sections 129-156. (Accessed 2014-07-27)
44.
ARHS&SS, Sections 157-180. (Accessed 2014-07-27)
45.
ARHS&SS, Sections 181-181.0.1. (Accessed 2014-07-27)
46.
ARHS&SS, Section 30. (Accessed 2014-07-27)
47.
ARHS&SS, Section 182. (Accessed 2014-07-27)
48.
ARHS&SS, Section 233. (Accessed 2014-07-27)
49.
ARHS&SS, Sections 31, 33. (Accessed 2014-07-27)
50.
ARHS&SS, Section 33(2). (Accessed 2014-07-27)
51.
ARHS&SS, Section 33(3). (Accessed 2014-07-27)
52.
ARHS&SS, Sections 192.1-201. (Accessed 2014-07-27)
53.
ARHS&SS, Section 202. (Accessed 2014-07-27)
54.
ARHS&SS, Section 203. (Accessed 2014-07-27)
55.
ARHS&SS, Section 204(1). (Accessed 2014-07-27)
56.
ARHS&SS, Section 204(4). (Accessed 2014-07-27)
57.
ARHS&SS, Section 206. (Accessed 2014-07-27)
58.
ARHS&SS, Section 207-208. (Accessed 2014-07-27)
59.
ARHS&SS, Section 208.1-208.3. (Accessed 2014-07-27)
60.
ARHS&SS, Section 42. (Accessed 2014-07-12)
61.
ARHS&SS, Section 213. (Accessed 2014-07-27)
62.
ARHS&SS, Section 214(2). (Accessed 2014-07-27)
63.
ARHS&SS, Section 214(6). (Accessed 2014-07-27)
64.
ARHS&SS, Section 214(5). (Accessed 2014-07-27)
65.
ARHS&SS, Section 2414(7)a. (Accessed 2014-07-27)
66.
ARHS&SS, Section 219. (Accessed 2014-07-27)
67.
ARHS&SS, Section 224. (Accessed 2014-07-27)
68.
ARHS&SS, Section 220(1). (Accessed 2014-07-27)
69.
ARHS&SS, Section 220(2)-(4). (Accessed 2014-07-27)
70.
ARHS&SS, Section 223. (Accessed 2014-07-27)
71.
ARHS&SS, Section 225.1. (Accessed 2014-07-27)
72.
In that case, three midwives will participate in the council of
physicians, dentists and pharmacists, though they can vote only on
matters concerning midwifery.
ARHS&SS, Section 225.2. (Accessed 2014-07-27)
73.
ARHS&SS, Section 225.6. (Accessed 2014-07-27)
74.
ARHS&SS, Section 225.3(1)225.4(2). (Accessed 2014-07-27)
75.
ARHS&SS, Section 225.3(2). (Accessed 2014-07-27)
76.
ARHS&SS, Section 225.3(5). (Accessed 2014-07-27)
77.
ARHS&SS, Section 225.3(4). (Accessed 2014-07-27)
78.
ARHS&SS, Section 226. (Accessed 2014-07-27)
79.
ARHS&SS, Section 227. (Accessed 2014-07-27)
80.
ARHS&SS, Section 188. (Accessed 2014-07-27)
81.
ARHS&SS, Sections 189(1), (5), 190(1)-(2). (Accessed 2014-07-27)
82.
ARHS&SS, Sections 189(2)-(4), (7), 191, 192. (Accessed
2014-07-27)
83.
ARHS&SS, Section 190(3). (Accessed 2014-07-27)
84.
ARHS&SS, Section 209. (Accessed 2014-07-27)
85.
ARHS&SS, Section 209.1. (Accessed 2014-07-27)
86.
ARHS&SS, Section 212(1). (Accessed 2014-07-27)
87.
ARHS&SS, Section 212(3). (Accessed 2014-07-27)
88.
ARHS&SS, Section 212(4). (Accessed 2014-07-27)
89.
An Act Respecting the Health and Social Services Ombudsman
(R.S.Q. c P-31.1) Section 1. (Accessed 2014-07-27)