Proceedings of the Special Senate Committee on Aging
Issue 3 - Evidence, January 28, 2008
OTTAWA, Monday, January 28, 2008
The Special Senate Committee on Aging met this day at 12:36 p.m. to examine and report upon the implications of an aging society in Canada.
Senator Sharon Carstairs (Chair) in the chair.
[English]
The Chair: Honourable senators and guests, welcome to the Special Senate Committee on Aging which, as you know, is examining and reporting on the implications of an aging society in Canada.
We have with us today David Munroe from the Canadian Automobile Association; Dr. Briane Scharfstein from the Canadian Medical Association; Dr. Michel Bédard from Lakehead University; and from The Rehabilitation Centre, we have Dr. Shawn Marshall.
David M. Munroe, Chair of the Board CAA National, Canadian Automobile Association: Thank you, Madam Chair and honourable senators. On behalf of the Canadian Automobile Association, I am pleased to be here today. The committee is to be commended for its commitment to issues facing Canada's aging population, particularly as we experience significant demographic changes that will have a fundamental impact on us all.
From its inception in 1913, CAA has been an advocate for the rights of motorists and the traveling public. We continue to work with the federal government, our clubs and our stakeholder groups to ensure safer drivers on safer roads in safer vehicles. The theme of our presentation, ``Safety and the Aging Driver,'' reflects this reality and the focus of the activities of the Canadian Automobile Association in the area of senior transportation and safety.
In Canada, we have the good fortune of being among the most mobile citizens in the world. In recent years, however, senior mobility has become increasingly central to the discussion of traffic safety and the CAA understands this better than most. Our association is intimately aware of the increasing average age of our membership which is no doubt partly because of the demographic trends in society in general. Due to the good work of the committee in its report, Embracing the Challenge of Aging, I will not spend time talking about the demographics of aging, but I would like to share a few of our key findings before moving on to the main points of my presentation.
In a recent online poll, the CAA found that of almost 300 respondents, 48.1 per cent indicated that they had their driver's licence for more than 40 years. The poll also found that 89.9 per cent of respondents felt that drivers should have a mandatory eye test when they reach a certain age. Similarly, 70.9 per cent of respondents felt drivers should have a mandatory medical exam at a certain age. While the poll is not statistically significant, it does provide context to the debate. Interestingly, it supports the data found in CAA's annual public opinion survey. In 2004, the most recent year for which data on aging drivers was gathered, a poll conducted for CAA by Earnscliffe found that 95 per cent of Canadians felt that drivers should have mandatory eye testing at that magic, certain age. Eighty-eight per cent felt that drivers should have a mandatory road testing once they reach a certain age. In both cases, the vast majority believed testing to be appropriate at some juncture and CAA has found that issues such as mandatory testing for vision and driving are of most concern.
Additionally, when evaluating driver capacity in relation to age, it is important to take into consideration factors such as physical ability, driver skill and road conditions.
In addressing the issue of senior mobility, CAA focuses more on this broad range of factors and less on age. So while age alone does not determine one's ability to drive safely, the conditions that accompany age do affect our ability to drive. It is important therefore to remember that not everyone's skill declines in the same way or at the same rate, but that age-related factors such as changes in vision, diminished hearing and slower reaction times can create problems. It is for these reasons that CAA advocates a comprehensive approach to addressing the issue of safety and the aging driver.
I would like to focus on three points that are fundamental to this discussion. First, ensure a balance between an individual's need for mobility and the public's right to road safety. Second, build broad support for addressing the issue of aging drivers and third, address the government's role in ensuring mobility for seniors and road safety.
The first point reflects the underlying principle behind CAA's approach to this important issue. Driving is a privilege and not a right and as such there needs to be a balance between the individual's mobility and the public's right to expect a reasonable level of road safety. In terms of competency, CAA encourages provincial governments to implement uniform programs of periodic re-examination of all drivers, not just aged drivers. CAA further recommends that drivers be required to submit to periodic eye and physical examinations and to provide the results to a licensing authority.
CAA recognizes that the ability to drive is important to independence for many seniors. We acknowledge that seniors require mobility for access to medical appointments, volunteer work and for social reasons. To accommodate these situations where seniors are able to safely drive under certain circumstances — for example during daylight hours — CAA recommends that governments introduce conditional licences for drivers who have reduced physical abilities that will impact their driving skills. This would provide these individuals with the opportunity to continue driving with restrictions rather than losing their licences altogether.
This brings us to the second point: How can Canada build broad support to address the issue of aging drivers? To address this issue, CAA has developed an action plan to address proactively the challenges that face aging drivers and their families. Since 1993, we have helped senior drivers by providing assessment and screening tools, additional training and sources of supplemental transportation. Specifically, CAA offers mature driving courses, senior and mature drivers' comprehensive workshops, assessment tools and online evaluations and tips sheets for our members.
Despite these measures, it is important to recognize that building a broad-based support for solutions that will ensure mobility for seniors in Canada requires a larger cast. Governments, health professionals, public transit authorities, driver training facilities, auto manufacturers and family members also have a role to play.
CAA therefore supports a strategy that includes conditional licenses for drivers with reduced physical abilities, improvements to road and highway design, changes in vehicle design that make allowances for the needs of aging drivers, and education and tools on driver and road safety to assist drivers and their families in determining competence.
The third area I would like to speak to is the government's role in ensuring mobility for seniors and maintaining road safety in Canada. CAA supports a strategy that takes into account more than conditional licensing for drivers with reduced physical abilities. The government should also consider the broader picture, including improvements to road and highway design to take into account the needs of aging drivers. Although Canada is in the enviable position of having world-class roadways and public transit systems, they are deteriorating at a rate that will cause significant challenges for seniors. Congested and poorly maintained roadways do not provide drivers with the confidence needed to navigate them safely. This can present an added challenge for seniors who may face difficulties seeing road signs, irregular pavement markers and are intimidated by roads that are increasingly faster, larger and more congested.
While the primary responsibility for many of these initiatives lies with provincial governments, the federal government also has a role to play, which extends to more than its responsibility for roads that fall under federal jurisdiction. The federal government has a responsibility to ensure that national road and highway policies are improved with seniors in mind. This can be accomplished by working with provincial governments to develop a coordinated approach to transportation planning, increasing access to public transit and ensuring that provinces have a uniform testing and evaluation method for all drivers.
CAA remains committed to working closely with all levels of government, including municipal governments to pursue policy changes, improve road infrastructure and design and improve public transit to ensure seniors continue to have mobility choices.
One example where municipalities can assist is demonstrated by a recent American Automobile Association study conducted in Michigan. Analysis of crash data found that low-cost intersection improvements had a greater benefit for drivers 65 years and older than for those 25 years to 64 years. The improvements included low-cost traffic safety engineering enhancements such as re-timed traffic signals, larger traffic lights and dedicated left-turn lanes.
With over 900,000 kilometres of roads and highways, Canada's vast geography will continue to present mobility challenges for all motorists. CAA is dedicated to ensuring driver mobility as long as safely possible. Aging itself is not an indicator of decreased driving skill and ability. We should focus on many solutions including conditional licensing, improvements to road and highway design, changes in vehicle design and road safety education that takes into account our aging population and the changes that need to be made to accommodate those drivers. We will continue to actively raise awareness through public outreach programs to educate motorists and dispel myths about older drivers.
Dr. Briane Scharfstein, Associate Secretary General, Professional Affairs, Canadian Medical Association: I will speak to you today on behalf of the Canadian Medical Association and our 67,000 physician members across the country. I want to thank the committee for the invitation to come and express our views.
I will make my comments in two areas, as reflected in the original questions. One is to outline the mechanisms and processes to ensure the safety and competency of physicians in their practices in which we have a long history of involvement and activity. Second, I will also touch on aging drivers because we also have involvement on that issue.
Relating to maintenance of competence, it links to something that the CMA has advocated for many years which is the elimination of mandatory retirement. This issue goes back some time and most recently was addressed through correspondence and advocacy in March 2004 when we wrote to Pierre Pettigrew and others outlining our concerns as they affect physicians where they have been at times subjected to mandatory retirement. In the background material we have provided, you will find more information on that subject. That information is a prelude to this discussion. I would like to highlight what the profession does to assure competency that we hope minimizes the need for any age restriction or mandatory requirement. At the end of my presentation, I will also touch on some of the physician resource issues and shortages that make that an even more significant concern.
In regard to ensuring the competence of physicians for whatever reason, that is a pre-eminent issue for any self- regulating profession, and none more so than the medical profession. In return for the privilege of being self- regulating, the profession has a number of ways to ensure competence to the public and to our patients. Essentially, they involve both individual as well as collective obligations to engage in life-long learning; to recognize and report on issues of competence, of either yourself or your peers; and to participate in peer review processes as well.
The individual responsibilities for that maintenance of competence are enshrined to some extent in our code of ethics. Among the numerous clauses that are contained within the code, four pertain specifically to the discussion today: the expectation that all physicians practise medicine competently; that they engage in life-long learning; they report to the appropriate authorities any unprofessional conduct; and that they participate in peer review. To put it simply, physicians are expected to hold themselves and their colleagues accountable for their ongoing competence, regardless of age.
I would also point out that we work from the premise that one's competence can be affected by illness and adversity at any stage in one's career. Therefore, the need to do that is not specifically reflected in one's age. Although there may be increased scrutiny in some programs linked to age, we recognize that is only one of a multitude of factors. The processes that ensure competence apply throughout the physician's life cycle.
Second, there are also a variety of mechanisms that are under the rubric of collective responsibility for both life-long learning and peer review. That plays out in a number of areas — first, through the credential process itself. If physicians are family physicians, they receive their credentials initially through the College of Family Physicians of Canada, or if they are specialists, they receive them through the Royal College of Physicians and Surgeons of Canada. In both cases, to obtain your credentials and maintain them, there are requirements linked to maintenance of competence and life-long learning. You need to undertake a specific amount of annual continuing education and report it to the certifying bodies.
In addition to the scrutiny at the collective level through the credential process, a separate provincial organization issues a licence. Simply obtaining the credentials to maintain your specialty status either as a family physician or specialist is not enough; you must also apply annually to renew your licence with a provincial licensing authority. In most provinces, that is a college of physicians and surgeons.
The licensing authorities, in particular over the last five to 10 years, have put in place a fairly robust process to monitor and assess physicians and their competence. Most colleges, in addition to an annual renewal of licence that requires physicians to answer a number of questions, also have a peer review process where physicians are randomly selected and required to have their office practises audited by their peers. Those processes tend to include what one might refer to as a 360-degree assessment, where there is a comprehensive assessment, including sampling questionnaires from patients, colleagues and co-workers and other health professionals.
In addition, physicians who practise in institutional settings — predominantly hospitals — have a more rigorous process in maintaining quality and competence. There is a credential committee and process whereby physicians are regularly reviewed and have to apply for their privileges annually. The quality of care provided in the institutions is monitored regularly as well. Rather than having physicians either completely in or out of practice, often their privileges may be varied over time, linked to declining competency in certain areas — again, avoiding a set age-restriction requirement to leave practice.
Finally, the Canadian Medical Protective Association, in addition to providing liability insurance for physicians, has a comprehensive set of educational programs that tend to be driven by identifying those areas of risk where physicians may be most likely to get themselves into difficulty. There is a fairly robust set of educational offerings that they have for physicians in those circumstances.
Taken in total from the individual physician's professional and ethical responsibilities, which are held quite close to the profession, to the collective activities of the Royal College of Physicians and Surgeons of Canada and the provincial licensing authorities, I would suggest that the profession does subscribe to the idea that competence is something that must be regularly reviewed and enhanced, but across the career life cycle and not just linked to a specific age.
These reviews and assessments have tended to be grounded in evidence, and have been gathered from years of experience — tools that can ensure competence. There is probably more to go and I think you will be hearing from the national umbrella agency of the provincial licensing authorities. You will probably hear a bit more about the concept of revalidation, where activity that is even more significant is being undertaken by the provincial licensing authorities to ensure competence.
All that to say that by virtue of those processes, we do think that the need for any arbitrary regulation based on age is not required. We would suggest that annual review processes and maintenance of competence expectations is the preferred route. There is additional background material provided to you in that regard, and I would be happy to answer any addition questions you might have about that subject.
I will touch on the second subject briefly, which was the question of medical fitness to drive. As you probably know, the profession has had a long history of involvement in determining fitness to drive for medical reasons. The CMA has been very involved and we produce a guide for physicians to assist them in making this determination. We are now on the seventh edition, which has been published in the last year or so, to give physicians assistance in helping with the determination of fitness to drive.
In most provinces, there is an obligation or an expectation that physicians will report where they suspect an individual may not be fit to drive. Anecdotally, I will tell you that is often difficult for physicians to do. The determination itself is not simple because it is not only age related. In the one section in the guide that is specifically on aging, it is interesting to note that it starts with the observation that aging, per se, does not necessarily compromise a person's ability to drive. It is the other conditions, medical and likewise, which accompany and become more likely with aging that, in fact, affect a person's ability to drive. Those are then covered in all the other sections.
We do have a bit of direction specifically linked to aging. What we know from the data that we have seen over the years is that healthy aging drivers are probably safer because of their experience. Again, we put emphasis more on assessing the conditions themselves.
I am also aware of a couple of issues that have come up with respect to physicians assisting with keeping safe drivers on the road and unsafe drivers off, and they are reflected in the requirements to report and the assessments that occur after. Hopefully, our guide helps in that regard.
Finally, I will make a couple of comments that are linked to the discussions of aging and maintaining competence, and that is in regard to the physician workforce. Although it is not a specific question for this particular panel today, I would point out that we have a desperate shortage of physicians in Canada, probably more than most OECD countries. We probably rank around 24 out of 30 among OECD countries in the number of physicians we have for the population. A significant percentage of our members and of practising physicians is over 65; 13 per cent is a close approximation. Those physicians are in full-time practice, and I would suggest that they are desperately needed. It is probably even a more significant issue for us in a time of shortage as we have now than it might be in a time of surplus. Fortunately, with the processes we have to ensure competence, we are fairly confident we are avoiding putting the public at risk by encouraging these physicians to continue to practise while into their seventies and even beyond. We are fairly confident in the vast majority of cases that they practice competently with good result.
The other issue that is not specifically here but which we have had some interest in is the care of the elderly generally, and if the committee will consider other aspects of aging and health, in particular, issues such as access to services for the elderly as well as the funding of long-term care, those are both areas in which we have had interest and have done some work and research. In the package we have given you, there is background related to both those issues, so we would be certainly happy to come back again to have further discussions on those subjects.
Finally, I would like to thank you for the invitation and for sharing a few thoughts, and we look forward to your questions and to adding any clarity that might be missing from the presentation.
The Chair: Thank you very much and thank you for raising those additional issues because they are of concern to your committee.
Dr. Michel Bédard, Canada Research Chair in Aging and Health, Lakehead University: Honourable senators, the mandate of the committee is to ``examine and report upon the implications of an aging society in Canada.'' Few issues are as salient for an aging society as the maintenance of mobility. While there are many definitions of ``mobility,'' I use a simple one: ``mobility is the ability to go wherever we want whenever we want.''
Access to transportation is crucial to maintaining mobility as we age. For most Canadians, access to transportation means access to an automobile and, typically, driving an automobile. The automobile is a great tool to maintain independence and enjoy a good quality of life. Unfortunately, for many older adults, but not all, aging leads to limitations of their ability to drive safely. Whether it is related to aging or health-related conditions, this phenomenon is becoming increasingly apparent in statistics. With increasing numbers of older drivers and greater distances travelled by them, safe driving is emerging as an important issue for Canadian society, both from an injury prevention perspective and a quality of life perspective.
We see three important areas where we can make a difference. First, we need to increase our understanding of the situations that are problematic for older drivers and of the factors contributing to those difficulties, and we need to develop better approaches to screen and assess potentially unsafe drivers. Second, we need to develop strategies to enhance safe driving. Third, we need to support the transportation needs of older drivers after they stop driving.
We have yet to fully understand what leads to decreases in safe driving among older adults. These can be age-related changes, for example, reduction in attention capacity, or health-related changes, for example, the development of cataracts. In most instances, older drivers develop compensatory strategies to deal with declines in their driving abilities, for example, not driving at night.
However, many older drivers will experience deterioration of driving that exceeds their ability to compensate for changes. Therefore, it is important to screen and assess older drivers adequately. To do so serves a crucial injury prevention role but also allows for the identification of individuals who may benefit from interventions to enhance safe driving, and it also prevents the use of age- or diagnosis-based labels to determine who should and should not drive.
It is important to emphasize that we are concerned with unsafe drivers, and there are some in all age categories, not just older drivers. However, we have yet to develop suitable screening methods and current assessment approaches are both expensive and lengthy.
It is also important to emphasize that the preferable approach to prevent crashes is to optimize safe driving. This approach supports the mobility and independence needs of older adults and can be focused on drivers, the driving environment and the automobile. Training and education programs for older drivers are emerging constantly, and recent evidence suggests that they may be effective to enhance safe driving. Changes to the driving environment, for example, better signs and road engineering changes, also appear to support safe driving. In addition, changes to automobiles, for example, advance warning systems, may also enable older drivers to be safer. Much work remains to be done to optimize safe driving, but this is a constructive, proactive approach that underscores the maintenance of quality of life for older Canadians.
Unfortunately, and despite attempts to optimize safe driving, many older adults will have to stop driving because of declines in their driving abilities, and others may stop for other reasons. For many who stop driving, the consequences can be profound, including reduced mobility, increases in depression symptoms and reduction in life satisfaction. The repercussions are not limited to drivers alone but may also affect other family members and the greater network of the drivers who often take over transportation responsibilities.
The impact of driving cessation highlights the potential inadequacy of current transportation alternatives to driving one's own automobile. It is important to realize that older adults who cannot drive are often not in a position to use public transit, assuming it is available. Many older adults living in rural areas may be forced to move to urban centres, possibly resulting in significant disruption in their lives.
In conclusion, aging poses a serious threat to anyone dependent on the automobile for mobility needs. Yet, a greater number of older adults than any previous cohort are relying on the automobile for transportation. This phenomenon will accelerate in coming years.
Most older adults want to live in their community for as long as possible. Enabling them to maintain their mobility is essential to ensure this goal and to support independence and quality of life. Supporting safe driving for as long as possible is one important strategy and also the preferred one by older adults. As a society, we will have to rely on multiple approaches, including the optimization of safe driving and the development of alternative forms of transportation to meet the mobility needs of coming older generations. Flexibility and innovation in the conception and implementation of those approaches will be necessary to meet the needs of older adults living in urban and rural areas.
Dr. Shawn Marshall, Associate Professor, The Rehabilitation Centre, Ottawa Hospital: Honourable senators, thank you very much for inviting me to present to this committee today.
I would like to address the issue of the older driver, and for today's presentation, I will address the medical issues of assessment of fitness to drive with regard to older drivers, identify current research initiatives for older drivers, and highlight research directions in older driver research.
With regard to background for older drivers, in North America, driving is a basic activity of daily living. Driving is important to everyone. It affects the ability to integrate into the community and to complete essential daily tasks, such as going to the grocery store and attending appointments. Loss of licence clearly can have affects, particularly, in older drivers. It leads to depression, isolation, loss of self-esteem, loss of housing and being forced to move from rural residences to urban residences.
Contrary to much of the public and media opinion, most older persons are healthy, and most older persons are the safest drivers on the road. The higher prevalence of medical illness and associated impairments are the explanation for the decline in driving ability for some older drivers, and those drivers are responsible for the increasing crash rates that are identified in the literature.
The problem will escalate. By 2030, 25 per cent of drivers will be aged 65 or greater; by the year 2025, the number of drivers aged 65 or greater will be doubled. At age 65, there is a prevalence of 8 per cent of the population with dementia; by age 90, 30 per cent or more of the population have evidence of dementia — again, across the spectrum of mild to severe. However, because a person has a diagnosis of dementia, does not necessarily mean that the person is not able to drive. Further compounding this — and what has led to one of the main constraints on identifying older drivers who may be at risk — is the notion that we can use a disease-based model to identify these persons. Driving is a functional task. For instance, in Ireland, 27 per cent of persons greater than age 70 have at least two significant chronic medical diagnoses. If you look at the medications to treat these chronic medical conditions, they are often on at least three of them. Clearly, this will have an impact on overall functional abilities.
When we look at specific medical diagnoses, we talk about increased relative risks; that is, someone's likelihood of having a crash versus someone else's likelihood of having a crash. However, that varies from individual to individual. Physicians, health care personnel and licensing personnel run into difficulties making decisions at that individual level. We can and have done systematic reviews showing that cardiovascular disease, dementia and conditions such as sleep apnea put you at a much elevated risk for crash. However, at the individual level, these must be interpreted, taking into account how the person is being treated, their driving experience and the driving conditions. Further, multiple medical conditions play a role. We know that the cumulative effects of multiple medical conditions can affect a person's functional ability to drive, but, again, we must take that in the context of environment and previous driving experience.
As has been pointed out by other members who are presenting today, physician reporting in Canada is unique. Today, seven out of 10 provinces in Canada have mandatory reporting by physicians compared to the United States, where only a few of the 50 states have mandatory reporting by physicians.
Physicians are put in a tough spot in this regard. The physician-patient relationship is often negatively affected. Clearly, you have some conflict. You are an advocate for the patient, yet, under law, you are required to report the patient as possibly unfit to drive. In addition, physicians have identified repeatedly through surveys that they have limited knowledge and education to make decisions. There is also lack of evidence-based information upon which to make these decisions. Although the CMA guide is a good resource to give direction to the physician, much of this is not evidence-based as to who should or should not drive. Again, it comes around to functional abilities of the driver. Resources other than the CMA guide exist throughout the world, but the guide is a good example of a good current resource available to physicians.
The aim of research is to improve the health, safety and quality of life of older drivers. Every research organization that I have been made aware of is not focusing on taking driver's licences away from older persons; they are focusing on prolonging the safe driving periods for older drivers. The focus is on assessment and screening at the primary health care level. Even when we know that someone has a diagnosis that may affect their ability to drive, when does this functional impairment become important to affect one's ability to drive? Those are pieces of information that we do not know.
Regarding formal driving ability assessments, there is great variability in the assessments that are carried out with on-road examinations. Again, they have not been standardized across provinces or states. Also, there is monitoring driving ability for progressive conditions. That is, someone passes an on-road driving assessment and is fit to drive but, unlike a 16-year-old driver who is expected to be healthy and fit and not have much change for years forward, with the older population, this can vary, particularly with progressive diseases. Also, there are focuses on interventions to prolong the safe driving period. Driver retraining, conditional licensing and technology in a vehicle to help older drivers must be further evaluated. Technology can hinder older drivers, for example, if we put in things that distract them within the environment. Things that we feel are helping might not necessarily help the older drivers who are not used to this type of technology.
It is my privilege to work with a group of researchers through the CanDRIVE research network, which is funded by the Canadian Institutes of Health Research. We have representatives from multiple provinces and conduct research with the aim of prolonging safe driving periods for older drivers. We want to use evidence and we want to integrate this into the practice of prolonging the safe driving period. We bring together researchers, seniors groups, clinicians, ministries of transportation and other governmental and nongovernmental agencies. We believe that this is approach we must use. We are all on the same side, all aiming for the same direction: Keeping people safe and driving.
There are other important initiatives that the committee should be made aware of. For instance, more recently sponsored by the Public Health Agency of Canada and the Canadian Association of Occupational Therapists, there has been a program called the National Blueprint for Injury Prevention in Older Drivers. This blueprint is looking at developing a strategy for implementing and evaluating the best evidence for prolonging the safe driving period. We are doing systematic reviews and contributing to existing information.
We need to put research evidence into practice and we need to have everyone working cohesively to put this information forward. That brings together those multiple partners that affect everyone. We need stakeholders, government, insurance companies, physicians and health care professionals to help everyone move along with this.
The Gerontological Society of America recently published some strategies and high priorities for research. Although this group is American based, it has Canadian representation with Michel Bédard, who is here today. The society's findings are consistent with ours note that screening, assessment and driver rehabilitation are high priorities for research.
We also have to bring together other areas, such as technology, which often isolates the older driver. We must also look at roadways. Although there are some instances where we are now looking at roadway conditions and how they are designed, it is fair to say that they were not designed with the older driver in mind when they were originally created. We must also look at vehicle modifications to make them more accessible and easier to handle for older drivers.
By using this approach and by trying to have all partners come together, solutions to prolong safe driving periods for older drivers can be better accomplished.
The Chair: Thank you very much. We have a number of senators on the list. I will begin with Senator Mercer. Let us welcome him back to the committee. It is good to see him back on his two feet.
Senator Mercer: It is great to be back on two feet. As I was off with my illness, I felt that I was becoming a study case for the Special Senate Committee on Aging.
I find all the comments interesting, but I want to go back to the original comments by Mr. Munroe. Other presenters talked about restricting driving and having a certain age for mandatory eye testing or mandatory driver's tests. But everyone danced around it and no one said, ``Here is a number that we should use.'' Is there an optimum age where we should be looking at doing mandatory eye tests and mandatory driving tests?
I am at risk of getting in deep trouble at home, because my 88-year-old mother still drives. I think this is an important issue, but no one seems to have put a finger on it — I suspect for the very reason that no one wants to be the one accused of saying that all those above age level X should be tested.
Mr. Munroe: You asked a question which we were anticipating, as you can imagine. I want to ensure honourable senators that we did not collaborate. We are definitely all singing from the same song sheet. Perhaps, as usual, the government has not caught up to the public yet, but we all agree that assessment is imperative. At the CAA, we are not waffling on this but understand that this assessment process needs to begin and needs to be done by a regulatory authority. We believe it is in the political area where this decision of competence begins to be measured.
I like to think we do not have any difficulties at the beginning of the process in training, examining and giving conditional licences to young people when they first begin to drive. It is seen as a privilege and the government, through regulatory agencies, gives young drivers that privilege because they have been able to prove their competence. When, at the end of their lives, that competence starts to leave, there is a reluctance to address that problem. We have no trouble pulling old cars off the roads so what about the drivers? We all recognize there is a point when we are no longer capable of driving. When a driver gets to that point, we need to have an impartial examination that can only be administered by a regulatory authority. It is unconscionable to put the weight of this decision on the family doctor. The family physician has a serious relationship with his or her patient and must have an engagement of trust, seriously violates in the minds of the patient that trust when the doctor takes away his or her mobility.
At the moment, it is voluntary. In our experience, when you have a voluntary program, those who know they can pass will take and it those who cannot will not come out to have their eyes examined when they cannot read the signs. This testing cannot be done voluntarily and the government needs to recognize this. Hopefully, through a subcommittee or via more witnesses discussing this issue, this committee can get to the bottom of when this must start. I feel strongly that it must start. It must be impartial and there should be no escaping the process.
Senator Mercer: You talked about conditional licensing used in certain provinces for young drives. Restrictions are put on them. How can that be policed?
In the case of young people, I suppose the police take a visual of the driver and determine he or she looks to be in that age bracket where conditional licences are granted. Then it depends on how long they have been driving; conditional licences can be removed due to experience. It is very difficult for the authorities to understand. It is the same for older people. How do the authorities police that if we are going do use conditional licensing, or are you suggesting self-policing by people who know the terms of the restrictions? Is that your position? If not, how do you see the authorities proceeding?
Mr. Munroe: I am not sure of the policy on that; I do not think we have one because we do not see that as our responsibility. We see our role as advocating for having assessments at certain ages. That must be done.
We seem to have no problem in regulating conditional driving licences for younger people. Perhaps they get into trouble and their conditional licence is discovered. They realize they should not be out driving under those conditions and they are penalized in some way. There are many spot checks.
I would leave the issue of policing to the committee to examine and find some solution to that problem. However, there are checks now; we are able to police them in those provinces that have conditional licensing. I hope that the same process could be used in conditional licenses for aging drivers.
Families should be involved. If an aged mother, father or relative has been given a conditional licence and the parent starts to go out when he or she is not supposed to, he or she should be spoken to. There are other conditions that can be put on those licences. Some people might be restricted from driving on 100-series highways, for example, and be restricted to certain roads in their neighbourhood. There are many intelligent restrictions that could provide a senior citizen who has a physical disability but who is not totally incapable of mobility to be allowed to drive in some safer manner.
Senator Mercer: Doctor Scharfstein, I have a practical case of a neighbour who has lost her licence. She complained to her family physician of having short-term memory problems. She is an elderly woman, but spry and in good shape. However, she also happens to be the care provider for her older husband. She is the only person who drives in the family. She has a daughter who used to be able to drive but who has been diagnosed with a debilitating disease that prevents her from driving. Do doctors take into account the effect on the family?
What happened to her is her family physician referred her for assessment and the doctor who did the assessment, of course, notified the province's department of transportation. She received a notice in the mail that her licence was suspended. Her family is now isolated; not only her family but her daughter's family. No one in that family can drive, even to the grocery store. Fortunately, she has good neighbours who pitch in and drive her wherever she wants.
Dr. Scharfstein: Your question prompts many thoughts, the first being that physicians are expected and required in most provinces to report a suspicion or a condition which might — not ``will'' but ``might'' — interfere with the ability of an individual to drive safely. The physicians do not make the final determination and that is a very important distinction. It is one that is applied rather generally where physicians are providing medical information for a variety of programs, whether driving or access to a certain type of insurance, et cetera. We would argue that the physician's job is to provide objective medical information. I do not think you want physicians to have to weigh the myriad issues that might come into play and their effects because that cuts both ways. As was referenced early by Dr. Marshall, physicians may be reluctant to report because they know all the things you referenced plus have a life long history of a relationship. From my experience as a physician in practice, one of the most difficult conversations you will ever have with a patient as a family physician is the discussion about whether a person should drive again or not. I found that more difficult than most conversations in terms of restrictions as you age. We have tried to encourage physicians to focus on their responsibility to report medical information. It is the responsibility of others to take that and a great deal of other information to determine when and how a person might drive safely.
Regarding the earlier question about a specific cut-off age, there is not a magic cut-off but the screening would occur more frequently as you age. That is one approach that has been taken in a number of places with conditions that become more likely as you age. It is not only vision; many conditions that might negatively affect your ability to drive become more likely over time. I think one would propose that if we have appropriate screening in place, that screening should occur with increasing frequency as one ages. Therefore, in one's 20s and 30s, you might have a vision test initially and 10 or 20 years later, you would expect to do that more frequently. If there was a standardized review or assessment process, you could cover the ageism issue by frequency of screening.
Currently, you are just relying on anecdotal reports and there are many people who have serious conditions who do not see physicians. They may not show up for screening and therefore may not be reported.
The Chair: To add to that, rather than having the attacks of ageism, which I think are quite legitimate, would it not be better to have reassessment at all age levels? Perhaps it would be less frequent in the 20s, 30s and 40s, but it would still exist. If it was not unheard of to randomly receive a notice from the Department of Transportation that a person at age 29, say, has to report for this assessment, the issue of ageism would be nullified to some degree. It would enforce the sense that driving is not a right, it is a privilege, and you have to be examined not only when you get your drivers' license but throughout your life. I know many poor drivers who are in their 30s.
Dr. Scharfstein: That would be highly supportable. A concern that we have generically that applies here specifically, is that physicians are left to adjudicate on the narrow scope of information that is the medical condition only. Physicians would rather not have to do that. They accept their responsibility in society because they have unique medical knowledge, but it would be better to have a process that clearly determines fitness to drive.
I often hear patients reflect that their doctor took their licence away or their doctor let them continue driving. I would suggest that neither is accurate, but it is perceived that way. It would be better to have a system that would adjudicate ability on a regular basis.
Dr. Marshall: I agree that as we age our health can be affected. You have to take into account that what you are trying to achieve is not necessarily achieved by an age cut-off. One of the common problems for older female drivers is that they stop driving when evidence suggests they are still competent drivers; it has to do with confidence. I refer the committee to a Scandinavian study dealing with age cut-offs. One country had mandatory age testing and the other did not. In the country with mandatory testing, many seniors did not go back to renew their licence because they felt they might not pass. However, they had a higher mortality rate for older persons experiencing pedestrian injuries. Therefore, what you are trying to achieve may not be the result with mandatory testing; it has to do with the notion of function.
Screening sounds simple. It means you are picking up people who may or may not be fit to drive but you have to go through the extra effort to show whether they are competent to drive. Like the analogy with cancer, you want a process that is sensitive, but you need the infrastructure to go through and assess individuals further, which can be challenging. It is easy to say we could use age-based testing, but it may be that screens that are more functional are the way to go.
Senator Cordy: I have had my driver's licence for 40 years and have never had to go back for anything. It is likely that others in the room can say the same thing. How would you go about it? The suggestion of retesting every 10 years is a good idea, and maybe every five years after you reach a certain age, whatever that happens to be. Can you see merit in that suggestion? Would it be workable to have people go back for retesting every 10 years?
Dr. Marshall: Typically, as we get older, we become more cautious and tend to have more driving experience. We can say confidently that many of the safest drivers on the road are older drivers. When we talk about function, we do not necessarily expect a decline in a person's functional abilities, unless that decline is health-based. However, a diagnosis alone will not determine a person's ability to function.
Diabetes can affect function but the diagnosis does not tell you much. There are people taking oral medications or on a diet to control the diabetes whose function would not be affected. Someone who took insulin could be at risk if his or her blood sugar gets too low. Others with diabetes for many years could have impaired vision that affects their ability to drive, but it varies from individual to individual.
Having people retest every 10 years may not be that worthwhile. We have to look at the overall benefit. Trends show that people become safer drivers as they get older unless there is some intervening event. Physicians and health care professionals have been brought in to assess this and have been given that responsibility. We can all agree that it may be difficult for the physician to do and possibly should be placed elsewhere.
Senator Cordy: All of you have indicated that physicians find themselves in a tough spot. Dr. Scharfstein said it is not the physician who takes the licence away, but I know families get together and say they are going to the doctor to see if they can have a parent's licence taken away. That is the reality.
One of our witnesses said that the doctor is the patient's advocate and the patient goes to see the doctor for help. Suddenly the doctor is the bad person because he or she has taken the licence away. It is an awkward position and the perception is that the doctor is in control.
It is possible that people who are told they cannot drive while taking medications that cause drowsiness will not comply with the prescription. If my doctor told me I could not drive while taking a certain prescription and my car was my only means of transportation, I might not take the medication. How do you get around all of those issues?
Dr. Scharfstein: I was involved with Saskatchewan Government Insurance exploring many of these very issues. This was about five to seven years ago and was based on the premise that we were not doing a very good job of identifying unsafe drivers from the medical perspective, a lot of collected information that was reported did not result in safer practices and was not evidence based. A few practical things came out of that. A pilot initiative, which was abandoned, suggested a separate cadre of physicians who would do driver medicals. That applies in the airline industry. A small number of physicians who have expertise are authorized to assess a pilot's ability to continue flying.
For example, we know of patients who will avoid going to their physician because they are desperately worried it may result in a problem with their continued driving. Some physicians are in the unenviable position of not knowing everything about someone to avoid that potential. Therefore, the thought was could we not have the specific physicians do driver medicals. They would do screening and be trained for that purpose.
The problem was the physicians who were doing those medicals found that the patients were not honest. Privacy legislation covering the insurance did not allow the screening physician to know in advance that the family physician sent Ms. Jones to see you because she is having seizures four times a day. The physician would see Ms. Jones and go through a list of medical conditions which she denied having and so would declare she is fine to drive.
It seemed that was a logical way to remove the onus from the family physician to a physician with that particular expertise. Then it is a matter of determining on the basis of good evidence how frequently that would be required.
The other thing that was done was to put in place a series of questions that the driver would have to answer which would screen for the majority of concerns when the driver applied annually for his or her licence renewal. If the driver did not tell the truth, it would have implications for his or her insurance. That was a simple initiative and easy to apply. On an annual renewal of your licence, you would have a few simple questions concerning your health. The vast majority of drivers, even as they grow older, are quite healthy and would not need screening. That way, it might help you to find those who do.
Senator Cordy: The shortage of physicians does not help.
Dr. Scharfstein: That compounds the problem. The other point would be the cost implications, which is why I think you need good evidence. The impetus to streamline the adjudication of information was that there was a flood of information coming in to the adjudicators of the driver insurance group that they were not finding all that meaningful. If you are going to hire physicians and others to do the screening, you need to have good evidence that there is a need for that because it would have a significant cost as well.
Senator Cordy: Mr. Munroe, you spoke about things the government could do and one of them was improve public transit. When you look at the number of seniors living in rural areas whose children have moved to urban centres, so they do not have a neighbour, necessarily, who can take them places, how should the federal government get involved in public transit?
Mr. Munroe: I think the senator asks a good question. In other forms, we have addressed this and the federal government is addressing it as well with their infrastructure payments to municipalities. Proper transportation requires population density. It is difficult to send a bus down a dirt road for 15 miles to pick up an elderly person.
The transportation issue is one for the cities and I am pleased to note that the government is now addressing that issue. Beyond that, we have some experts in the audience and perhaps one of them would like to address that subject.
Christopher White, Vice-President, Public Affairs, Canadian Automobile Association: The Canadian Automobile Association has been long been advocating a national highway plan. When we are talking about rural transit, it is clear a national highway plan would not address that and that the infrastructure that the federal government has provided to the provinces and municipalities would not affect that. The CAA has been looking for and long believed in the need for greater collaboration between the provinces and municipalities on this issue.
What we have heard consistently is that there is a fair bit of criticism on the part of municipalities toward the federal government because of the off-loading of services. Therefore, I think perhaps one of the things that could be looked at is if the transportation committee could work more closely with the provinces and the municipalities. You could do something like we used to have in the City of Ottawa when I was growing up, which was the OC Transpo bus that would go around to the local communities and pick up people at their homes. Often in local communities in cities, everyone knows where the older people live and who among them does not have access. That may be an opportunity for the municipality to invest in some funding along those lines.
Clearly, at a national level, it is a very difficult issue. I do not think it is necessarily just the federal government's responsibility. It is a multi-level responsibility of all governments. However, where the federal government could help the provinces and the municipalities is with the investment of funding.
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Senator Chaput: I have some questions of a general nature for all of the witnesses.
I look at this issue from two different angles. First of all, a person can lose their driver's licence because of their dangerous or risky behaviour. The individual may have committed an offence or acted recklessly, or may be suffering from an illness. With the exception of the latter case, taking away a person's licence is seen as punishment for behaving a certain way.
As for whether a person should lose their driver's licence when they reach a certain age, this action can be perceived as being unfair toward the older individual and a punishment of sorts. In my opinion, it is indicative of a lack of respect.
One of you said earlier that driving is a privilege. I have to admit that I never consider the matter in that light. Driving is not a right, but a privilege.
Perhaps we should take steps right away to make everyone more aware that driving is a privilege. That is why people must pass a test and why they must first obtain a learner's permit. People need to adopt a new attitude. We all have parents. And I can assure you that they consider driving as their right, not as a privilege. Therefore, we need to look at this issue a different way.
Certain types of driver's licences come with restrictions. A number of senior voluntarily agree to curtail their driving or to refrain from driving in poor weather — I am talking about rural communities, because I come from one such community. Some people cannot drive at night because of reduced visibility.
Many seniors already limit their driving. Perhaps we should consider rewarding them for their behaviour or providing them with an incentive of some kind. Perhaps they could qualify for lower insurance premiums, lower licence renewal costs or a reduction in their CAA membership dues.
How do you feel about adopting an approach that would reward people, rather than punish them, which is what the current perception seems to be?
Dr. Bédard: First of all, let me say that I agree with you completely. Age should never, under any circumstances, be the reason for taking away a person's licence.
It is important to have proper testing procedures in place for drivers so that they have confidence in our ability to rate their skills fairly.
Age is a factor that can impact a person's driving skills. However, it does not mean that seniors can no longer drive safely. This is an accepted fact.
As for voluntary restrictions, as you pointed out, most people voluntarily limit the amount of time they spend behind the wheel. They realize that they may have problems or that they are not as comfortable driving in certain conditions. As Mr. Marshall said earlier, according to some findings, it may be safer to issue licences with restrictions. However, some cases are more problematic, such as cases of people with dementia. Occasionally, seniors do not realize that they are experiencing problems, or they get behind the wheel when they really should not be driving.
The whole question of incentives poses a bigger problem. I have already discussed with insurance companies the possibility of offering discounts to seniors for new driving lessons. It is not a simple question. Since most seniors already drive safely, their premiums are not very high as it is. There are not a lot of options out there. The important thing is not to take action that could be deemed punitive. That is why I emphasize the importance of maximizing and improving safe driving. Most of us do not drive as well as we should. We need to employ safer driving techniques, and perhaps even take a driver's refresher course every five years. People talk about periodic testing, but not about making people take the occasional new course. It is important to adopt a comprehensive approach to dealing with this issue.
Senator Chaput: According to your research, are more accidents caused by seniors behind the wheel?
Dr. Bédard: Research shows that taking into account the average distance travelled, seniors are at a slightly higher risk of having an accident than the average age driver. However, in absolute terms, seniors have fewer accidents because they drive less. Because they present a lower risk, their insurance premiums are much lower.
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Senator Chaput: Does anyone else have a comment?
Dr. Marshall: That is a very good point. It has to do with the culture of how we perceive driving. I agree that it is perceived as a punishment, almost a loss, and not only is the health loss associated with it, but also the driving loss is associated with it. Among the many things we prepare for in life, the notion of driving retirement is not prepared for. When you lose your driver's licence, not only are you losing your ability to get around, you are losing your residence if you live in the country, your independence, your social club and so forth. All of those are losses.
We have to look at anticipating that, and it is why we need to come together from different avenues. For instance, many people give up driving even without mandatory reporting or being taken away by physicians because their health deals them a blow. Many average individuals live up to a decade after driving, whether they end up in a nursing home or long-term care facility or even their own home. It is not something that is unexpected, but we have to turn it around.
The other important thing is some people do not seek out their physician for reversible health care problems because they are afraid it will affect their driving status. It has to be turned around as glass half full versus half empty. It has to be seen as a positive, namely, let us look at what we can do to keep you driving versus the threat. Unfortunately, our culture is one of ``we want your licence.'' It is as if we want to grab it back from you whereas it is quite the opposite. We all want older drivers to keep on driving. I think even the insurance industry will agree that some of their best drivers are older drivers. It is just the attitude or the prevailing perception that it is the case that we want to take this away from people, so, of course, they are timid and fearful. We all want to be safe drivers. We do not want to be the cause of an injury to someone else or to ourselves. You have raised a good point, namely, the perception out there, and it has to be addressed.
Senator Stratton: This discussion has been interesting, reaching that age myself and watching the body slowly deteriorate over time. It is amazing what you do in your youth that you pay for now. It does not take much.
The Chair: Telling stories?
Senator Stratton: Not deliberately.
Senator Mercer: We may want to turn the cameras off.
Senator Stratton: Exactly. There is an interesting story, and this is a sidebar. The famous actress Bette Davis was asked, when she was getting older, what it was like to get older. She looked at the interviewer and said, ``Growing old ain't for sissies.'' It is true.
My point of view, and I agree with some the presenters, is that we have to encourage independence for as long as possible. To me, that is a fundamental principle.
The issue of independence as long as possible, no matter where you live, is the fundamental principle on which you operate. Looking at that principle, we can ask how serious this problem is. Is it serious enough that we need to do mandatory testing at specific ages? I liked Dr. Marshall's statement about the two Scandinavian countries, one which had mandatory testing and the other did not. You do not see a reason to substantiate the mandatory testing at certain ages. I know one retired senator now in his nineties who is completely independent and drives around quite well. I look at that and say I hope I can reach that age and do that.
If you have that as a second principle, then you look at it on the basis of who is ultimately responsible. You have to put a lot of the onus on the person. I like the idea of Saskatchewan where drivers fill out a form on their annual licence renewal that asks whether you have a medical condition. That is a good idea.
Family and friends are critical to what is taking place. If someone is isolated rurally, you would think there would be family and friends around, for the most part. However, when we were looking at Canada pension payments and people collecting Canada pension, we found that men, in particular, which was the surprising part, do not apply. You have to go and find them. It may be that the onus is put on the municipality only to that degree, that if there is a problem that they have to go and find someone. I do not think you can put the onus on the municipality to do something.
The third principle that you need to go by to allow that independence as long as possible involves the physician. If someone goes in for a medical, and the physician finds something, I do not know how he or she gets rid of that responsibility. I do not know how you can say the physician should not have to do something. For example, my ophthalmologist might say there is a certain level by which I have to be able to operate, because it was in conversation when I was having my eyes tested, to have the ability to drive. If you read the CAA conditions in different provinces, most of it concerns vision.
With those points that I listed, what I do not like is for government to get too involved in this simply because you cannot control everything. I get a little concerned when we say we can have government do this when, in effect, family and friends do it and the individual responsibility is there to do it. The responsibility of the testing bureau would be to ask the questions on the annual licence renewal form. I do not know how physicians get out of it. I would ask for your comments, doctor.
Dr. Scharfstein: I do not think physicians need or want to get out of it. Physicians have a basic premise, and it is balancing their patient's rights and respecting their confidentiality and what you owe society. In every case, physicians have to weigh that, and the underlying assumption is that a physician is obliged to report any and all medical circumstances where there is a serious threat to society or to other individuals, including driving.
A better example is child abuse. Physicians are required to report suspicions, even though that seriously compromises a patient-doctor relationship.
I do not think physicians want to get out of that; I think they understand that responsibility. They simply do not want to be put in the position of being the adjudicator of those issues. Physicians simply want to report medical conditions and leave it to the regulators to determine eligibility. There is a sense that in some way physicians are determining whether people can or cannot drive. What we are saying is that they ought not to. For example, the majority of unsafe drivers on the road are not unsafe because they are old or sick; they are just not safe drivers. Statistically you see that it is the young and new drivers who have higher accident rates.
With respect to your comment on whether we should do anything, I would agree with your point. We ought to have a lot of evidence first about the relative safety or lack of safety of aging drivers before we put in place anything robust or difficult to enforce. I am not sure that all that evidence exists yet. That may be required first.
Mr. Munroe: The senator has outlined concisely the problems with the voluntary system that we enjoy today. It is not very successful.
We have clear evidence that the public is ready to move ahead with this. I mentioned in my presentation that Earnscliffe did a study for us in 2004. About 95 per cent of Canadians who responded to that survey indicated that they were ready for mandatory testing at some point. The question is, at what point?
I can give you some anecdotal evidence. In many cases, we abdicate our responsibility. We all must take ownership of this problem. Committees like this, the government, the regulatory agencies and the CAA are trying to do our part. We do not necessarily agree with the voluntary system. There are certainly ways that it can be strengthened, as my learned friends have indicated. Perhaps that is the least difficult, most politically astute way to deal with this, because we then are off the hook. However, to apply mandatory testing at some point will certainly resolve the problem.
To make Dr. Marshall's point, at age 12, I recall going down to the ball field in Cape Breton, where I grew up, and being told I could no longer play little league because I was too old. I was heart broken, but that was the very first indication to me that the world had limits. We grow up with limits, and I think Dr. Marshall made an incredibly astute point, namely, that we do not apply that same culture to driving. We seem to believe, as Senator Chaput said, that we have a right to drive. Obviously, we do not. We believe at the CAA, and I believe, that there are conditions that come along as you get older that can indicate a problem. It is certainly the responsibility of the medical profession to do this, but we are uncomfortable with applying these rules and intruding on these doctor-patient relationships. We think it is wrong for society to do that. The way to eliminate all these problems is to have mandatory testing.
I recently saw a case where we abdicated our responsibility. It was a sad case in Halifax — you may have heard of it. An elderly gentleman was going up Robie Street, a divided road with 50-kilometre speed limit. This gentleman came up to a crosswalk with flashing rights — it is well known — that goes across to the Halifax Commons. All the cars stopped. This young lad came out and ran across the crosswalk. The elderly gentleman hit him and killed him. He continued, drove up and parked at the side of the street. The police came and this gentleman sat in his car. When he finally came out of his car, at the behest of the police, he had to have his four-legged walker. That is the first problem. This matter, of course, went through the courts. The second problem was who was at fault, who should be blamed and where are the lawsuits going, and so on? However, six months later, he was given his licence back and he is still driving, as far as I know. There is something intuitively wrong with a system that allows that kind of situation to continue. Obviously, that gentleman had problems that should have been addressed. We just said, ``No mandatory testing. We do not need to know. We do not have the right to know.'' Perhaps there was no physician involved, which also is unconscionable.
We believe that mandatory testimony must happen at some time, which needs to be determined. The CAA would like to participate in the debate and the discussion, if you should choose to have a subcommittee or some other body struck to try to work this out. We would like to work with our fellow physicians. Dr. Marshall made unbelievable points, as did Doctors Scharfstein and Bédard. What am I doing with all these doctors? It is great to be with them and it is wonderful to have the opportunity to understand their position and to put forth ours.
The Chair: Thank you. We have run out of time, but there is one area I must deal with — and it is one, Dr. Scharfstein, which you raised. It has nothing to do with driving and everything to do with the whole issue of professions judging other members of professions as to their competency to continue to practice. I am a teacher.
My experience as a teacher is that we did not do a very good job of weeding out those who were not particularly good at their jobs. It is fine to put these things in a code of ethics, but, realistically, as we have physicians who are getting older and older, will there not be some stronger limitations that we will have to put in place? If Dr. Keon were here, he would be the first to say that he did not believe that he was capable of doing the intricate heart surgery that he did over a certain age, so he stopped doing that type of surgery. He also went on to say — and this is on the record — that he would not want a 70-year-old neurosurgeon operating on him, thank you very much. If we will not have mandatory retirement — and that is a given, because it has been tossed out straight across the land — how will we ensure that competent people in a variety of professions are functioning and incompetent people are not?
Dr. Scharfstein: First, I take the premise, absolutely, that we must do that. It is no more important than in the medical profession. I tried to point out that much has been done. I guess whether enough is being done is the question.
You pointed that out Dr. Keon should not be doing open-heart surgery at his stage in life, but he is still a very valuable contributor as a medical practitioner, in a more restricted way, like restricted driving. The vast majority, if not universally, of physicians, as their skills decline, either restrict on their own or often, through privileging, are restricted to maintain a safe practice and they stop doing invasive surgery but still do other things. I think the premise is correct. I would actually be so bold as to suggest that the medical profession has probably done a fair bit more than most in that regard. We separate the advocacy groups like our association from the regulators. The colleges have a public mandate. There are usually 50 per cent lay members on their council. Most of their processes include public members on discipline and on credential committees, et cetera. Over the last 10 years, there has been a significant increase in the number of non-physicians who are part of that process. They need to be transparent because the assumption is that you do not police yourself and you need to demonstrate what you are doing openly. I think there is a lot there. I will note the Shipman case.
I think there is a light shining on the whole profession. I have kids who are teachers and brothers who are lawyers and I agree with your point that not all professions take the issue of self-regulation as seriously as they should or could. I do not mean to imply that it is perfect the way it is, you must have of the profession involved in self-regulation. They will know more about their colleagues and their competencies than non-physicians, for example. We often hear the term now not ``self-regulation'' but ``profession-led''; that is, the profession takes a lead role, but with the public. I would suggest that in looking at that, to the best of my knowledge, the processes in place within the medical profession might serve as examples for other professions as well. I guess it is a balance of risk. I would be so bold as to say that I think in the vast majority of the circumstances that those are assuring relatively safe practices. It is not perfect for sure, but what you will hear from the Federation of Medical Regulatory Authorities of Canada is that the new initiative is something called ``revalidation.'' Adding that next level of assurance, where there will be a requirement to annually demonstrate what you are doing to maintain competence might be part of the missing piece that you reference.
The Chair: Thank you very much. Thank you to Mr. Munroe, Dr. Scharfstein, Dr. Bédard and Dr. Marshall. This has been a very interesting panel.
Our next panel includes Laura Watts from the Canadian Centre for Elder Law Studies, and Jeanne Desveaux, President of the Alzheimer Society of Nova Scotia. She is also the past National Chair of the Elder Law section the Canadian Bar Association.
Laura Watts, National Director, Canadian Centre for Elder Law Studies: As is often the case, we first heard from the insurance companies and the doctors and then the lawyers take the floor.
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Honourable Senators, thank you for inviting me her today. I am the National Director of the Canadian Centre for Elder Law Studies, or CCEL. The CCEL began doing research in 1999 and was incorporated in 2003.
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The mandate of the Canadian Centre for Elder Law Studies is to improve the lives of older adults in relationship with the law, to advance law reform issues of particular interest to older adults and to be a leader and public legal education and information on these issues. It is a non-political, non-partisan organization that works collaboratively with key national and international stakeholders, including federal and provincial organizations, clinicians, judges, academics, et cetera. We engage in scholarly research and writing, we draft and comment on legislation and we engage in knowledge mobilization events. Today, I would like to talk about three particular issues and I have three key recommendations flowing from them.
How do we ensure that older adults are afforded the respect and self-determination of their individual rights as full members of Canadian society as protected by the Canadian Charter of Rights and Freedoms? My first issue is one of rights. How do we as Canadians address the complex issue of varying mental capabilities — what we have heard referred to today as mental competency, mental capacity or mental capability — such that the older adults are able to freely use their rights and to protect broader society as well? In other words, the balancing of rights issues with regards to mental capacity is my second point. My third point is questioning how Canada can be a leader in reducing social vulnerability and elder abuse and neglect issues.
I will put a face on these issues because each of our experiences with aging is personal by it is very nature, and I often say it beats the alternative. I would like to tell you about Gladys. While this is not her real name and she is an amalgamation of a few cases, it will highlight some of the issues we are addressing, namely that of rights, mental capacity and vulnerability or elder abuse and neglect.
Gladys is an 89-year-old woman with some physical frailty in the form of hip problems; she has lived in her own neighbourhood in Western Canada for 40 years and has raised her children. Her daughter lives in Toronto and the other son lives nearby but is a bit of ne'er-do-well and there is an interested nephew in Halifax. This is very representative of Canadian society. There are studies to show the average distance between family and friends in Canada is something in the neighbourhood of 400 kilometres in urban areas and 3,000 kilometres in rural areas. I will talk about how she has been enriched by her neighbourhood, how she is engaged in her faith group, et cetera, and she has known her neighbours for years. However, they are changing, too, so she does not know all of them the way she once did.
The stairs in her house are a problem for her so she does not go upstairs as much as she used to. However, she is still emotionally connected with her house, the place where she has had her family. She is fiercely independent and has been actively resisting the helpful advice of family and friends that she should move into some type of long-term care facility. The daughter, Susan, particularly wants to have her mother move into the nursing home because the daughter feels disconnected living in Toronto. She feels that if her mother was in a nursing home, her mother would be safer. However, we have studies that prove that may not be the case.
Her son Daniel has always been a bit of a ne'er-do-well and is suggesting his mother make him her power of attorney. He has young children from a variety of relationships and is finding it very difficult to enter the extraordinary housing market in Vancouver. In addition to the power of attorney, he is also suggesting she might immediately put the house in some type of joint tenancy arrangement with him. This would assist her in avoiding probate taxes; we would not want to have to pay the government anything. He also said Gladys does not need a house that big and should be helping the younger generation and doing the family a favour. She does not need that much space anyway.
Both of her children have been pressuring her significantly as well as the nephew in Halifax. She has been vociferous in her resistance and that has been calling attention to her ``inappropriate'' and ``unseemly behaviour'' against going into the residence where she should be. There was also one comment that perhaps for a woman, in particular, she should not be so argumentative. This is a common issue and one we do not talk about openly.
Related to our first key issue, how would Gladys be subjected to Charter discrimination issues? I will talk about the law and reflect on section 15, which is our age-protected area of discrimination. In particular, I would like to parse out the issue of living at risk and decision making.
We have in our society this notion that people should become compliant with age. I certainly hope that within my family I will continue in the broad tradition of being as irascible and independent as possible; it seems that will be the case. Gladys is a full adult in the law and pursuant to Canadian federal legislation has the right of all full citizens; including right to say no and the right to live her life the way she wants. It is true she is having some short-term memory issues, and if she does not take her medications relating to her diabetes she can have some fuzziness in her thinking. However, she says she is in no danger to herself or others, but the family disagrees, and this is where the problem lies.
Gladys is subject to what I would consider gender discrimination, a hidden issue when it comes to older adults. We recently completed a project called Aging with Challenges and one issue was aging identity issues. As people get older, they become less identifiable as individuals and become a blank slate of an old person. We know that is not the case and what may be appropriate for an old man and appropriate for an old woman in this social norm indeed can be very different. Older women have a different narrative about what is appropriate: She should become more compliant with age, but Gladys is resisting that.
Given the aging population of Canada, my number one recommendation is that the next ``ism'' we need to address as a federal government is to recognize ageism. We talk about it, but it is not been ranked as a rights based issue in Canada. The discourse has been about something that is out there in media, but the federal government should recognize aging not just as an issue but as a social movement. This has been done in other countries in Europe, Japan and Australia.
It should be recognized formally as a social movement akin to the disability rights movement or the feminist movement. Once named as an ``ism'' it can be identified as a key area of research which can be supported. We have a paucity of research on ageism in Canada and that is one area that if recognized as a social movement, we can move with federal dollars and support to focus around these issues on a broader basis.
The second key issue is how Canadians address the complex issue of mental capabilities. This really is the elephant in the corner. We have a problem with lexicon in Canada and even more problematic perhaps as a multicultural nation based on a bicultural model, we have a wide variety of languages enriching our country, but when dealing with very specific terminology, it can mean different things for different people.
I have been in discussions with psychiatrists, social workers, lawyers and bankers in one room using the same words and not two of them were talking about the same thing. There has been little research done in Canada about what mental competency, mental capability and mental capacity mean. Do they mean the same thing? I say they do not mean the same thing.
In addition, we have not looked at how things are measured. It is interesting that in some jurisdictions there is a functional notion of capacity. This is some of the discourse you were hearing today. Do you have the functional ability to drive, and how is that related to a mental capacity to do your cheque book? My husband will say I have never had the mentality capacity to manage my cheque book but have had the fortunate circumstance of having my drivers licence since I was 16 years old. They do not mean the same thing. We need to look at how the notions of capacity, competency and capability may or may not be measured. We need language first. The lexicon needs to be addressed and that is a research issue.
In this case, Gladys seems to have challenges recognizing the mental impact if she did not take her medications, but I said they were manageable so that is an issue of capability.
I suggest that the appropriate question in Canada should be capable for what. If we address this notion as a standard starting ground, the lexicon can unfold from there as opposed to giving a blanket statement about a number of unknown issues. Specificity is important and that can bring us to where we need to be.
If capability is challenged, it has enormous social and civil impact. It includes the impacts of denying section 3 and section 7 rights pursuant to the Canadian Charter of Rights and Freedoms. If a person is determined ``incapable,'' he or she loses the right to vote, the right of liberty, the right to marry — or in some cases, the right to divorce. That person loses the right to make guardianship and asset decisions. The person becomes a nonentity in law. It is the most severe impact one can have and if we do not understand what our terms mean, the impacts indeed are desperate.
It is an enormous power and my concern is who assesses the assessors? As a lawyer, as a member of the national executive of the Canadian Bar Association and in my positions on a number of boards, I can tell you I have had the fortune and misfortune to see a variety of capability assessments performed. I witnessed a court case where a prescription pad with the notation ``Madam X is not capable'' was admitted into court. The judge took it as evidence. I saw another case where the judge threw it out as evidence.
Who assesses the assessors? Who decides who knows how to do that? In Ontario there is a system of capacity assessments, but there have been criticisms about how that is done. In other jurisdictions, no one is certain who assesses it. I suggest to you that the federal government should establish a program to determine what tools and mechanisms would be appropriate for creating capacity assessors.
With regard to the third issue, in what way can Canada be a leader in reducing social vulnerability and elder abuse, I do not accept the notion that older adults are vulnerable. I accept the notion that all people are vulnerable to certain degrees based on certain conditions. You are vulnerable if you are poor. You are vulnerable if you are subject to racism. You can be vulnerable because you are subject to ageism. I know that all people are not vulnerable and all older adults may or may not be depending on their circumstances.
However, in this case, Gladys is subject to increased risk of social vulnerability. She has family that has one interest while she has another interest. She has a physical incapability and possibly a mental issue. Should she sign that power of attorney over to her son, or put him as a joint tenant on the house? She is at significant risk.
Most people do not recognize the authority of a financial power of attorney and what that means. I have worked as a member of the British Columbia Law Institute for the Western Canadian Law Reform Consortium to create a harmonized or unified power of attorney. Our report is due out this month, so that these matters can be better addressed in different jurisdictions.
When an older adult has been abused or neglected, his or her access to justice is severely constrained. Civil remedies become inordinately difficult. How can Gladys retain a lawyer if her son empties the bank account, mortgages the house and leaves? She cannot; she has no funds.
She can try to go to the Advocacy Centre for the Elderly, currently Canada's only civil legal aid clinic that deals with the legal issues of seniors. By contrast, the United States has a firm system in place with clinics in most major cities and in every state.
I am pleased to be part of a project to open the second legal aid clinic, which will be in Vancouver, on July 1. However, considering our population, the access to justice issue is one that must be considered.
Elder abuse legislation or ``vulnerable adult legislation,'' as it is sometimes called in Canada, is not a panacea. It varies broadly from province to province; it can only respond to suspected abuse and neglect; and its effect can severely and negatively influence older adults in exercising their rights to live at risk in the community.
Many lawyers I know say ``I am glad for the legislation but I spend half my time defending seniors out from under it.'' The question of capacity assessments is fundamental to that and we do not have that infrastructure.
I am also concerned with the discourse of family and friends that I hear time and time again. I love the notion that older adults would be surrounded, as all people should be surrounded, by family and friends; but we know in Canada this aging cohort may not have that support. We are farther away from our families and friends than ever before. This cohort also has a longer lifespan and may outlive many family members and friends.
Similarly, we have heard of a significant crisis in the availability of family physicians, which is often, if you do not have family and friends, where that next narrative goes to. The family physician will help. I am a fan of family physicians but we know that there are not enough family physicians and many older adults do not have either set of support. We need to think more broadly. If we have legislation or we have recommendations, the capacity assessment piece again is very important.
My last recommendation is that the federal government should take leadership on issues of harmonization and unification of both laws and policies that deal with elder abuse vulnerability and capacity assessments — in particular, with regard to documents such as powers of attorney, health care directives and health care consent laws.
Access to justice for older adults must be significantly supported by the federal government. I understand that may be difficult; but without the harmonization and unification, we know that jurisdictionality can be used with significant difficulty. I think my colleague will speak to some of the differences with provinces and some of the difficulties with that.
We recommend that the federal-provincial-territorial working group on senior safety be supported, and examine ways to look at tools for legislation to be harmonized in Canada. Also, this should involve the work of the Federation of Law Reform Agencies of Canada as well as the organization called the Uniform Law Conference of Canada. These organizations are happy to work together toward these ends and, with some support, can do so very usefully.
The issues of rights, mental capability and elder abuse are varied and difficult. In summary, we would make the following recommendations: federal leadership on knowledge mobilization, accepting ageism as a next social movement; exploration of the lexicon of ``mental capability'' ``capacity'' and ``competency,'' and different understandings of these notions, as well as working toward standards as to how to assess the assessors; and working with organizations such as the FPT, FLRAC and the Uniform Law Conference of Canada, to examine tools and mechanisms to develop harmonized laws and policies to reduce elder abuse and vulnerability.
Jeanne Desveaux, President, Alzheimer Society of Nova Scotia: I am Acadian but I would not attempt to be as articulate as my friend was so I will not attempt to speak French this afternoon.
When I was asked to come here, I wondered what I could offer since so many experts have come before you. I think what I can offer is the fact that I do practice elder law. I do work with the elderly. I do work with physicians — I work with geriatricians — and I come from a health care background. I was a nurse for many years before I entered the practice of law. The only area in which I really devote my time is the area of elder law. That is where my heart is because seniors drew me to this area.
I work with many people who already have a diagnosis of a dementia. I often represent either the family that is attempting to have someone made the subject of a guardianship application or someone resisting those efforts by a family. I have people come to me with different dilemmas and often my clients say to me, tell someone. This afternoon I will tell someone, and that is you.
I am not one for sticking to notes. I have heard everyone and they have covered many areas, but I do want to read to you a quote from a law case from 1909. I use this very often and in my briefs to court when I am trying to make the point.
The eye may grow dim and the ear may lose its acute sense and even the tongue may falter at names and objects it attempts to describe, yet the testamentary capacity may be ample. To deprive lightly the age thus affected the right to make a will would often be to rob them of their last protection against cruelty or wrong on the part of those surrounding them and of their only means of attracting towards them such help, comforts and tenderness as old age needs.
That passage was printed in 1909 in relation to an estate case, but we could expropriate some of the comments, whether it be the issue of driving or many of the issues regarding growing old.
I have heard the various presenters going before me, and we were asked to speak to driving. I have a case in particular that I want to draw to your attention.
I had a woman who is now deceased; it is an estate file. At one point, the physician had reported to the appropriate motor vehicle branch in Nova Scotia that this woman could no longer drive. She lived in rural Nova Scotia, and her physician had a very close link with her. He said he felt like he abandoned her; she felt like she was abandoned. Her words to him were ``how could you do this to me? Look what you have done to me.'' That was her mobility. That was her means of getting into the city from rural Nova Scotia to her specialist.
I asked him why he did not ask the palliative care physician to make that call. He said, ``I could not do that because she is going to need him even more than me.'' That is a horrible trade-off to ask our physicians to make. The doctor abandoned her in essence because they lost their confidentiality, their doctor-patient relationship. She could no longer trust him at the time in her life when she most needed to trust him because he was the one who had to report her.
Of course, the family were all fighting over the money so they were not concerned so much about her driving. These things really do happen on the ground. I face this daily in my practice.
On the other end of the spectrum, I sit on the board of the Alzheimer Society of Nova Scotia, and one of our board members drives his motor vehicle. We call him the cover child of the magazines for someone with dementia; he drives after dark and he drives very well.
A diagnosis of one of these conditions is not a death sentence. It means that you are going to die more likely than not from a particular disease. However, that does not mean that right now, as soon as the doctor puts the ink to the page, you are no longer capable. It does not work that way.
The key comments in regard to Senator Keon were very interesting, that he recognized when his capability had diminished in regard to practising surgery. We think of that as being a very precise technique, when we think of going into someone's heart. It is very commendable that he recognized that; but had Senator Keon been diagnosed with a dementia, perhaps he would not have had the insight into his condition to know that now is the time to step back from the operating table.
When we have one of these types of illnesses, our thought processes are different. We lose the insight; we would not be able to appreciate the seriousness of the situation because in our mind, things are going on as they had before.
It is just like the man who drives up the one-way street in the wrong direction. There is a scrambling, and that is what happens. It is commendable that Senator Keon was able to recognize that, but the person with dementia may not recognize that. Various speakers this afternoon have made those points.
Our fundamental principle is always to encourage independence, so what can we do to encourage someone with a dementia who is perhaps driving and wants to continue to drive. There have been various comments about having different licensing schemes of retesting. I would support and recommend that as I am sure many members of the bar would.
Often, we are asked to account for our activities when we are filling out documentation. Our insurance companies ask us different questions in order to provide insurance coverage. Our governing bodies, whether it be the practice of medicine or law or nursing — any of the professional bodies when you go to renew your licence will ask you questions that will red flag whether or not further investigation is required. It is not a large onus to put on individuals that they complete forms that would be self-reporting in the sense that if there needs to be a recall or retesting, then it would be appropriate. It is not an infringement on a right because driving is a privilege.
I would like to speak briefly about the vulnerable elderly, as we call them. I do not believe either Ms. Watts or I like the term ``vulnerable elderly,'' but we hear it often. I like to think of the ``well elderly'' and ``aging in place,'' but not so much ``vulnerable'' because it makes us a victim or a patient.
I would like to discuss one of the cases I dealt with, and it was a very high profile case in the media. I certainly have the family's consent to speak to it because it has been broadly telecast from one end of the country to the other. Only under the auspices of his of power of attorney, a husband had retained me to have the power of attorney validated and the fact that he did represent his wife's interest and then he hired us as attorney's lawyers to look after his wife's interests in the essence of what occurred to her.
It is a case in which the woman had been removed from the jurisdiction of Canada and taken to England because there was a war over who should have possession of the body.
This woman was very intelligent. She had a background in dementia and was an expert in cognitive impairment. She had drafted documents, and in the time period she did them, that was sufficient. That is what everyone was routinely doing. She was aware that she had a dementia. She went to her physicians with her symptoms. They supported that diagnosis, there was further testing and then she was sent off to her lawyer to get her affairs in order. She did that, and she thought everything was in place. However, a family member had concerns, and if he had legitimate concerns, we have mechanisms in this country. We can report through the Adult Protection Act. Things can be investigated. This individual removed the woman from the Province of Nova Scotia, from Canada and took to her to England. It was reported to the RCMP, and the RCMP referred it on to Crown attorneys for an opinion of whether or not charges could be laid, supported or if the person could be convicted. The problem turned out to be, as we have uncovered over many months, in the provisions of the Criminal Code of Canada, in particular, in relation to the kidnapping provisions. Those provisions speak of someone deemed to be competent. For any of us familiar with a person with dementia or with nursing homes in general, if I went into a nursing home in Ontario, British Columbia or Nova Scotia, and I went to a dementia unit and I said, ``Would you like to come home with me?'' half the people in that unit would follow me out the door. To suggest to someone, ``Would you like to get on a plane with me and come to England,'' the likelihood will probably be ``yes,'' and the person will go along obediently. That is what happened in that particular case. That is what the facts suggest.
What has been clouded is after this individual had been moved out of the jurisdiction, is became a struggle between the various families and interests as to the appropriate thing to do with her. She became more of a chess piece. Her humanity was lost.
Now there is a struggle between the various families as to who is telling the truth and what do the facts suggest. Of course, the media became involved because this story sold newspapers. It is not a good news story but it is one with lots of drama and innuendo. That is what we were faced with. That woman's best interests are not being served by not looking at the Criminal Code, in particular. We had an individual who had a PhD and who had gone out and signed the power of attorney. She had appointed her spouse, yet someone came in and said, ``I do not like what he is doing and I checked into the Adult Protection Services people of Nova Scotia, and they just did not cut it for me, so I will just take her back to England.'' He snubbed his nose at our laws, and we allowed it because there was nothing in place to prevent it. People should not be able to move people out of this country because they do not like our laws. If it does happen, then the individuals should be brought back to our country to be dealt with here.
That did not happen in this case. I am not faulting the RCMP, and I am not faulting Public Prosecution Service. I am faulting, perhaps, the archaic language in our Criminal Code and the fact that when it was printed, it did not recognize that we have new diseases. We have dementias such as Alzheimer's, Lewy body disease and frontal lobe dementia. We have these various diseases that impact on someone's mental capability. They did not exist, or when they existed, we called them things like ``senile dementia.'' Someone was put into a nursing home and forgotten. The medications and treatments we have today were not available then. We need to recognize these new entities and bring the provinces and the federal government together in the Criminal Code. That would do a great deal to prevent elder abuse.
There are provisions in the Criminal Code that talk about abuses of power of attorney, but we have legislation in the provinces that deals with powers of attorney differently. The work that they are doing in the Western provinces will give us a great template for the rest of the country to look to as a document that is user friendly across the country.
I will tell you about another case of an Ontario woman. In Ontario, it is necessary to fill out two powers of attorney, one for finances and the other for health care. The woman in this case had taken care of both of these documents. One of her daughter's was leaving the country for employment reasons that required two signatures on her particular document, so the other daughter had the decision of, ``What do I do? How do I manage my mother's care while I am living in a different province?'' She moved her mother to Nova Scotia. It is easier to get forgiveness than permission. The rest of the family was not consulted. The two daughters had the power of attorney. They did what they deemed to be appropriate. Then it became a power struggle. The other daughter threatened that maybe she should move her mother back. We had no choice other than to go before the courts in Nova Scotia to get a guardianship in place. A guardianship gives you a court order in Nova Scotia, and with a court order, if someone removes someone from a jurisdiction, then at least you can go to the police and say, `` I am the guardian, I have an order appointing me the guardian. Would you please doing do something?'' It is just like when a parent is accused of moving children from one jurisdiction to the other. The custodial parent says, ``He was the access parent. He was supposed to bring those children back at 5 o'clock on Sunday and he did not. Do something.'' Without having that type of paper with an adult, basically, the person can end up being a chess piece. I reiterate they lose their humanity and that is what we need to prevent.
The next case is one that our Chief Justice of the Supreme Court quoted from an article I wrote on the case. One afternoon, I received a phone call at my office, and it was an elderly woman calling me from a nursing home and she said, ``My daughter has sold all my property. I am in a nursing home. I do not even have money to get my hair cut. I want to know what my daughter did with my money. Can you help me?'' I did not know if I can help her. Then her son intervened, and he lived in another province. He got wind of the fact that his mother had been moved from her home community to another area and placed in a nursing home in another area so she would be isolated from family and friends. His allegation was this was done deliberately. There was a lot of family conflict in this particular case. I went to see what had happened to her properties. All her properties had been sold. They were ocean-front properties with a very high value in Nova Scotia. Those properties were sold or transferred. What the woman wanted to know was whether she could have money to get her hair cut, not, ``What did you do with my million dollars?'' It was, ``I have no money.'' First, I spoke to her again on the telephone, and then her son went to various agencies and again he was referred back to me. It was a civil matter. It had to be dealt with within the family, reportedly.
I met with the woman and she said, ``I am not asking for my daughter to be prosecuted, but I would like to have some money and I would like to know what she did with my money.''
In that particular case, the woman had had a series of mini strokes. She was brought in through an emergency department and a physician very readily said she had a dementia. In essence, she probably had some delirium, because dementia is progressive; it is not reversible. She did regain function, but here she is with this label of being demented. What do you do? She is in a nursing home; they have it documented that she has dementia. She is in an isolated nursing home in rural Nova Scotia and there are no geriatricians. The family physician does not want to give me any information. I sent a letter off to the daughter thinking that this would not be difficult. She would give us an accounting as to what she did with her mother's money and give her mother a bit of money every month — her mother does not want her prosecuted. However, the son might have his own agenda, too. He is upset because he does not know where his sister spent the family inheritance. My focus is on the mother and she wants $20, not $2 million. I asked the daughter for an accounting under the power of attorney. The daughter hired a lawyer who sent me a letter saying that her mother is incompetent, she has dementia, she cannot instruct counsel, go away; it is none of your business. I thought, ``He does not know who he is dealing with.'' I did not go away. That is the reality of it. All the mother wanted was money for her hair. She did not have any money in her purse. It was not that her daughter had used this power of attorney when it is questionable whether the mother was even able to give counsel when she gave instructions for that power of attorney.
Often, I will have lawyers as well as family physicians say to me, ``But the person only scored 23 out of 30 on a mini- mental state exam.'' I say, ``Your point is? So what!'' They then say, ``She has dementia. She is only at 23.'' I say, ``I am a 23 if I have a migraine. I am sure you are 23 some days. In fact, I am sure I am only an 18 some days.'' That exam only detects the presence of a condition; it does not detect the severity or what is impacted.
As Ms. Watts said earlier, when we talk about ``capable,'' capable of what? We need to look at how these tests are being used and who is doing them. We must start assessing the assessors. This is something that must start from the top and work down, not from the bottom up.
I do have some recommendations. When I think of how easy it is for that daughter to go into a bank with her mother and say, ``I have my mother's power of attorney.'' She can go into a lawyer's office and say, ``I want to sell my mother's ocean-front property. I have her in a nursing home in another part of the province.'' Some red flags should go up to both the lawyer and the bank. Does the bank offer independent legal advice? It has to offer independent legal advice. I think I am correct when I say this — and I think I am protected by these walls if I am incorrect — banks want to have proof of the identity of an individual so that if a spouse tries to go off and mortgage the family home, the wife must be offered independent legal advice. Yet, the daughter can go into the bank with a power of attorney and mortgage the mother's property and no one offers any independent legal advice for the mother. Banks are a federal jurisdiction, if I am not mistaken, and I do think there is an onus on the bank. Some banks are doing a fabulous job, but it is not mandatory, if someone comes in the door with a power of attorney, that someone has looked behind it.
I get really cranky when I have the person who is appointed as attorney call me and say, ``I went to the teller to withdraw money from my mother's account or from my aunt's account and the bank teller told me I could not do that; that is a power of attorney. How do I know that she really gave it to you?'' That makes me cranky. In a sense, the bank is being protective of that individual. The answer lies somewhere between the two extremes; we have to meet in the middle.
In Nova Scotia, if you are selling someone's property with a power of attorney, the power of attorney has to go on record at the registry of deeds. If someone is operating under a power of attorney, no matter what province it is, maybe there needs to be some sort of red flag — that is, something to raise awareness. We have a no-fly list. We think it is an infringement on people's rights, security of the person, and so on. There are all kinds of things we like to throw out there as excuses to get rid of some of these things. We call seniors our vulnerable population, yet there is nothing to protect them. Maybe it is as simple as having some sort of database.
I would like to talk now about physicians and education and the law and education. We have a need for geriatricians in this country, yet, I think every one of them has sent me an email in terms of the comments that I should make to you. We do not have enough of them. We need more. The family physician says that your mother scored 23 out of 30 on a mini-mental state exam and, therefore, she has dementia. But that is done without a referral to a geriatrician. Your mother should go off to a lawyer and get a power of attorney. Get that power of attorney and then sell your mother's house. There is a slippery slope when it comes to the abuse of the elderly. We can stop it with physicians having more education in that area. It should be fundamental. We need specialists but we also need our family physicians to have more education in that area.
Are they getting it? In some areas, they are. Maybe physicians voluntarily get more education, but I think it must be mandatory. It is the same for law. I do not think someone should be coming into a lawyer's office with a daughter sitting there instructing the lawyer. I do not think all lawyers do that. I think that would be the exception, not the majority. There must be knowledge that someone can be diagnosed, they can present well, depending on what type of dementia they have, but they could be compromised when it comes to giving instructions. We have to go behind and there must be an onus to do so.
The concerns and issues are not a simple matter. They are not private family matters. They are not the responsibility of the province or the federal government. All of us have the responsibility. The federal government can set the pace.
When I see the work that the federal-provincial-territorial working group has been doing in regards to elder abuse, I applaud that work. In one sense, I get a lot of work from it, as do other lawyers in this area, because there is awareness in the community. My reason to go into this area was not to become rich — that will never happen. However, the fact that they are getting the message out and people are getting more information is fabulous. That shows how effective that one working group is, in particular.
I see the growth and the potential of what can be done from the federal level to spread the word across the country so that we can protect those in society as well as us. It will be us and our children. We must do something about it. Remember: Age is not a disease.
The Chair: Thank you very much. I received a document from our researchers the other day, and I actually wrote on top of that document, ``age is not a disease.''
Let me put a hypothetical question to you and ask for your response. An elderly woman, a severe diabetic with serious physical capacity problems, is in a nursing home but does not want to be there. She wants to be home. The family does not want her home because they know she probably would not take her insulin at the appropriate times, probably cannot bathe herself appropriately, probably cannot ensure her total physical safety but she wants to be there; she does not want to be in the nursing home. What do you do?
Ms. Desveaux: I have a couple of questions that I need to know. Does she have money? Whether she has money or not, it is still cheaper to maintain the person in his or her own home with assistance than to provide that same care in an institution. Really, it should not matter if we have money. That is an argument that I continually make in this country. We have a universal health care system. We are supposed to have portability, so you should be able to take your mother from Ontario to Nova Scotia and that would be covered off. You should not have a waiting period. There should be access, and the care should be able to be provided in your community.
We had a case out of Nova Scotia in regards to mental health supports that went all the way to the Supreme Court of Canada. They said that the woman should be provided the care in her own community with the support network. The same thing goes with aging. Diabetes can be maintained by our various partners and organizations that make home visits, such as the Victorian Order of Nursing. Her pills could be monitored for compliance. However, she does not want to be there.
I am neutral when it comes to politics; I simply want the elderly to be cared for. I recently had various conversations with Alexa McDonough who had the opportunity and the privilege of visiting Ms. Munroe in England. She was appalled at the woman's condition and how she had deteriorated. However, she saw a system at work in England where the patient's advocate is truly the patient's advocate. They have a system that is almost like our child protection legislation, but not in that sense. They advocate for that person. The elderly diabetic woman who does not want to be in the nursing home would have someone such as an ombudsman to whom she could go to fight her case. Her rights, not the rights of her family, should be paramount. It should not matter whether or not the person has money. We know there are allegations in this country that if you have money you can jump the queues; if you need a CT scan, you can get around the wait times.
When it comes to the elderly, it is cheaper to put more money in the right places such as providing care in the home. It does not have to be an economic argument but it always comes down to that.
Ms. Watts: There is a section 7 issue that I want to bring back to the Canadian Charter of Rights and Freedoms. If she is mentally capable, whatever that means — and I want us to be thinking a lot about who has made that assessment and with what tools — regardless of physical frailty, she is able to make her own decisions and she has the right to act as foolishly as she wishes.
I often say that I plan, at a certain age, to spend most of my money on shoes. I am a well-known shoe-lover and I plan to spend my money on them at that age. Will it be prudent? No. Will it enrich my life? Absolutely.
If the woman we are talking of should choose to live three months in a situation at risk and if she is mentally capable of doing so, pursuant to section 7 of the Charter of Rights and Freedoms, she has that right. If it is infringed upon, she has a section 15 remedy saying she is been discriminated against based on age.
A public policy answer to that also draws upon my colleague's response. We know from some preliminary work at the Public Health Agency that Health Canada and the provincial governments have addressed but have not taken action on a national strategy on home care. In particular, I draw attention to whether this woman is palliative. If so, we need to be looking very seriously at hospice and palliative options regarding quality of life. We know the most expensive place for that woman to be is in that long-term care home, second only to an acute care bed. It seems to me that Canada is doing her no service and she is doing no service to Canada. Therefore, she has the right to make her decisions and I recommend that we support her in any way we can, especially if it is a matter of palliative or hospice care. She has the right to make the decision.
The Chair: In this country, we also know that if you have a lot of money and can pay for home care support, you can remain in your home. However, only a small minority of Canadians can live that way. We also saw a famous case in New York where an elderly woman had money and she still did not get the care she required because she had a son that did not ensure she had the money to do it. She had to have a grandson advocate on her behalf in order to secure those resources for her.
It is left to the family and, to be fair, this is a very caring loving family that just wants the best care for their mother. They are terrified that she is not going to have quality care if she moves back into her own home. This is not about money or even about power. This is about their legitimate desire to do what they believe is in the best interests of their mom, with their mom in conflict saying that it is not in her best interest.
The dilemma I think many of us will face in that kind of a situation is: ``How can I educate the Canadian people to recognize that this is not a second childhood my mother is going into? This is her adulthood and she is entitled to make those decisions even though I am not comfortable with those decisions.''
Ms. Desveaux: You used the word ``comfort.'' You are more comfortable having your mother cared for because you do not have to worry about her getting up at night and tripping over the foot stool on the way to the bathroom. You can sleep better at night, but it is not about your comfort; it is about your mother's comfort. Therefore, your mother has the right to live at risk.
Senator Mercer: I think it is interesting that you use that terminology. Let us turn it around and go back to when we were parents of children. Children move away from us and we spend time fretting about what they are doing and if they are getting up in the middle of the night and tripping over the stool, et cetera. All of us who are parents had to learn to live with that type of concern. We do not necessarily feel comfortable with it all the time.
I think you are correct: I am very concerned that people go for the quick fix of putting Mom in the nursing home. It is extremely expensive, not just for the family if they are paying for it, but it depletes all the resources that the parents have built up over their lifetime. It also depletes the resources of the province that they are living in.
In my estimation, I do not think it provides the quality care that people say it does. It provides safe care because if they are looking for safety, they are probably going to get that in a nursing home. If looking for quality, they will not necessary get it unless they are paying top dollar and, as Senator Carstairs says, that is not necessarily the case, either.
I am interesting in talking about Great Britain where patient advocates are truly that. Perhaps this is something we should pursue a little further. Perhaps there needs to be an advocate for the aged and that advocate indeed works for them and not for us, nor for the bank, nor the family nor the life insurance companies. The government may pay for it but these advocates do not work for the government but for the aged person who feels aggrieved.
I really sympathize with the family because most families want the best for their aging parents but the families also have to respect the decisions that their parents make. I like the idea that we can be foolish in old age.
How do we get to the point where we have an advocate? Should the advocate be a federal or provincial officer?
Ms. Desveaux: I see a role for both jurisdictions. When I think of public trustees, for example, not all provinces have a public trustee and a public guardian. In Nova Scotia, we have a combined office made up of one person with minimal office staff. She is the hardest working lawyer in Nova Scotia. I am using that example because that I am familiar with it.
We have the federal government and provincial governments. We have federal and provincial civil servants. We could have oversight from the federal level and best practices so that the provinces could carry it out. It could be legislated to the provinces' responsibility but there could be federal jurisdiction in terms of federal oversight to ensure best practices so things would not be done in isolation in rural British Columbia, the City of Halifax or in francophone Quebec. I use that example because sometimes things are done differently in Quebec; its laws are different.
We would look at the best interests of the aged person, not what makes a son in British Columbia taking care of his mother in Ontario more comfortable. I cannot see why it cannot be done. We can appoint public trustees. Why can we not appoint ombudsman or someone as the seniors' advocate?
We need to appoint someone with the background and knowledge of those conditions, not someone who will take the interests of the physician who has had those interests shaped by the family, or the banking officer in the rural community who knows the family will do what they want anyhow. We want someone who is independent, who truly is that person's representative. It can be done.
Senator Mercer: Regarding your description of the portability of health care, I think that is really something we need to explore. I benefited from the portability of health care. I pay my taxes in Nova Scotia but I have had health care in Ontario. It is interesting that if you go through the process, you go up to a point where there are reciprocal agreements between the provinces and they only go so far. That does not just affect the elderly; it affects all of us. How do we fix that and what are the specifics that you see missing in the portability for the aging?
Ms. Desveaux: The specifics are if you were living in a nursing home in Ontario and you are under the OHIP or Pharmacare plan of that province and you go Nova Scotia, there is a waiting period. One client had to move her mother into care; of course, there was no bed available because there are people in acute care tying up beds waiting for nursing homes. She had the option of putting her mother in a small home with around-the-clock care which the family had to pay for. The family had to take on all of the health care expenses during that time, whereas it should be transferable.
I have one of the private health care providers giving me insurance, which many of us do — most of us get extra coverage so that the ambulance trip to the hospital can be covered. This just gets me started on another line of thought about nursing homes where it is not covered any more. I get militant about these things with regard to the elderly. However, I think you should be able to leave downtown Toronto and move to downtown Halifax and your health care should go with you. Your coverage should go with you but it does not.
As far as those enhancements, we have a senior who may have been recommended by her specialist that she take a particular trade name medication. When she moves to another province, she will have to go through another referral to another physician to get that same prescription written so she can have access to that medication because it is on a restricted list. We need to look at that. These are discriminatory practices that need to be addressed but for some reason, it is okay to discriminate against the elderly. We have to get rid of that perception before we can do anything about the reality.
I want to comment about nursing homes. I worked in a nursing home for more than 20 years, and I during that time I did not see one case of elder abuse. I saw really good quality of care. In defence of nursing home staff, I can say that most of them are not there because they have to be; they are there because they want to work with the elderly. The nursing staff does not care if you are rich and had a home in the south end of Halifax or Richmond Hill in Toronto or Mount Royal in Quebec. It does not matter if the elderly person has money or not the staff still provides the same quality of care. I think I should make that clear since I have worked in that area. The care is consistent.
Senator Mercer: That is the one thing that we would all agree on; the quality of care delivered by the people is excellent. The question is, are there enough people to deliver the care?
Ms. Desveaux: No, there are not; there is a crisis.
Senator Mercer: So the level of care does deteriorate due to lack of staff. They can only serve so many people in an eight- or 12-hour shift and they can only give the quality that time and physical restrictions permit. I agree that it is not because they do not want to; it is because they are not given the resources to do that.
Senator Cordy: You both have been fascinating to listen to. I wanted to say forget the question period, just keep talking. There are many Nova Scotians around the table so we are all familiar with the case you spoke about that has been well documented in the media. You wonder what is right and what is not because it is a case of he said, she said — or in this instance, he said, he said — and the woman herself is sort of shunted aside.
Ms. Desveaux: In that particular case, she made her plan and it does not matter if I do not like it.
Senator Cordy: That is my question. Here is someone very intelligent, at least from what I read, who put all her plans in place. One would feel secure that if you take the time to do that, your plans will be carried out. That was not the case; her plans were not carried out, much to the chagrin of many people who have put their plans in writing, I would guess. Do we have to update the laws or is the Charter enough?
Ms. Desveaux: Only if we have the money to issue a Charter challenge and take every one of those cases to court.
Ms. Watts: Then you would have to find a lawyer expert in the area.
Senator Cordy: We have two experts here today.
Ms. Desveaux: In that particular woman's case, it should not have happened. As soon as they got word she was in England, the Royal Canadian Mounted Police should have been contacting Scotland Yard and they should have been knocking on the door. She should have been on the next plane back, escorted by a nurse from England — a geriatrician or whatever it took. She should have been brought back here, put into a specialized unit at the QE II and assessed by geriatricians. They could have called in an independent geriatrician to assess her. We even tried to have an assessment done by a geriatrician in England and he would not touch it with a 10-foot pole.
She should have been brought back here. She did everything right, but in her particular case, there was a power of attorney, not a court order. When they went to the police and said she is gone and he took her, the problem is that she went willingly. My argument from the beginning was that if you go into any nursing home and say ``Do you want to come home with me?'' they would follow you out the door.
Her rights were not even looked at. There was a lack of education by the people who were receiving the information in England. I think we have learned a lot from that case and I think that there will be changes to the legislation. When I do documents for my clients, I do not put the health care decision making into a regular power of attorney for property unless they insist; I put it in an advanced health care directive.
In Nova Scotia, in particular, we have the Medical Consent Act, where you can name a proxy — a decision maker. You can delegate that authority to someone to give consent. However, when you look at that legislation, you are looking at giving consent to treatment.
My argument would be — as with the lawyers who volunteered to work on this file with me, as well as some physicians — when it comes to dementia, everything is about consent, so that should have been enough, but it was not. We obviously need more education in this area.
When I do an advanced health care directive, I include that medical consent clause. The person names someone as a proxy but then they do their instructional type of directive — the living will type of directive —, which guides the hand of the substitute decision maker as to your wishes.
Ms. Munroe had articulated her wishes to various individuals. Her physicians knew her; they were her friends. This should never have happened but it did. When my clients come to me, they say, ``You are the lawyer who looked after the Heli Munroe case. Will that happen to me?'' I cannot tell them that it will not happen to them as long as we have legislation like the Criminal Code that says if you do not like what your sister's husband is doing with her, take her to another country. Until that is changed, realises that this legislation has to be changed, then it can happen again.
I am confident it will happen again because this case is now a he said, she said type of scenario, which has taken away the emphasis from where it should be, which is on Ms. Munroe herself.
None of the allegations has been substantiated. He made various allegations but because the authorities in this province did their role in investigating and it did not pass his smell test, he took her away. Really, we should not be able to flaunt the laws of this country but it was done in that case.
Senator Cordy: Should we change the law?
Ms. Desveaux: Absolutely.
Ms. Watts: I sit on the Federation of Law Reform Agencies of Canada and I am a staff lawyer at the British Columbia Law Institute, which is the law reform body of British Columbia. I cannot say there are any laws in any more specific need of harmonization, if not unification, than the laws that govern health care consent, advanced care planning and powers of attorney.
We have one initiative of the Western provinces but this is an unfunded project. The Law Commission of Canada and, before that, the Law Reform Commission of Canada no longer exist. There is no body in Canada that can look nationally at how to work on uniform issues, with the exception of the largely unfunded Uniform Law Conference of Canada and the largely unfunded Federation of Law Reform Agencies of Canada.
There is a quip that we have no more corners of our desk to work off of. As a result, the national work is being done by concerned lawyers who believe passionately that we need to move forward. In this sense, I think federal leadership is very important, whether we reconfigure how that work is done. I have met with the Minister of Justice and with some other law reform agencies, and we have suggested that we work together in a new way.
One of my recommendations to this committee is to pursue how law reform across the country is funded. I recommend that the committee do this with an eye to understanding that is it important for all societies to have a national responsive law reform commission, be it federal or a funded federation of provincial and territorial commissions. It is a disgrace that Canada does not have this type of commission. Further, it neither serves our economic nor responsive purposes to be without such a body.
You may or may not know that your power of attorney for finance or your advance care plan, which could look like an advance directive, like a health care directive or like a number of different things in a default, is entirely provincially governed. That is fine, except for the fact that it will likely not be recognized, enforced or understood when Gladys goes to visit Susan or when Susan goes to visit the nephew in Halifax.
If I am visiting in Ontario, my plans from British Columbia will not be recognized easily and indeed may not even be thought to exist. We do not have a national system for the review of laws and we do not have a coherent system to look at these most critical and personal issues, particularly for the aging population.
Ms. Desveaux: As there are so many Nova Scotians in this room, I will say that in the Heli Munroe case both Peter MacKay and Alexa McDonough came forward, and they understood that there is a gap in the law. They understood that the law needs to be reviewed. Mr. MacKay said that the government is going to do something about it. His actual words were, ``I'm from the government and I want to help.''
Please, help Heli Munroe, yes, but help all the other older Nova Scotians and older Canadians who could be removed from this country. The daughter in New York can take the mother from Toronto if she does not like what the daughter in St. Catharines is doing. It can happen.
Senator Cordy: Many seniors are isolated. I want to make it clear that not every senior is abused by his or her family, but there are situations in which seniors are very isolated and very dependent on families that may not be treating them in the way they should be treating them. How do we get the information to seniors overall, but particularly to seniors in isolated situations? It does not have to be isolation in a rural area; it can be isolation in an urban area. How do we get information to seniors about their rights?
You spoke earlier, Ms. Watts, about work you are doing in British Columbia, and Ms. Desveaux said she hoped this would be a scenario repeated across the country. What types of things are you doing and how can we do it?
Ms. Watts: I have a wonderful success story to tell you. The Network of Centres of Excellence, which is a federally funded body combining the organizations of CIHR, SSHRC and NSERC, has funded about $1 million per year for four years, the National Initiative for the Care of the Elderly. I am privileged to be the theme team leader for the end- of-life and palliative care division. I also work on other policy aspects for the National Initiative for the Care of the Elderly.
This is a marvellous organization that brings together clinicians across the disciplines, which is unique in Canada. It brings together the original core group of geriatric nurses, doctors and social workers, and we have added in a few lawyers. Ms. Desveaux and I also advise in that capacity. It has expanded to occupational therapists, physiotherapists and a broad number of other groups that are interested in supporting older adults.
For the most part, the people who do this work do it voluntarily. Again, there are only so many corners of the desk that we can work from. People who want to work in these areas look at five themes including dementia, care giving and end-of-life issues, and an elder abuse theme team has been newly established.
It also partnered with the IRDCs and has received a bit of funding from the federal government in terms of its international divisions to look at ways in which we use knowledge mobilization from other countries from which Canadians have come. It began with nine core countries and has expanded to others. We look at how to mobilize information across cultures and across language difficulties.
This initiative is wonderfully supported in terms of the people who are willing to do the work. It needs continued support as its funding runs out, which I believe will be in about a year and a half. I can strongly recommend the work of the National Initiative for the Care of the Elderly. It has the ability to get into the teaching curricula, the professional curricula and professional requirements and licensing. It pulls in business and industries that manufacture goods for older adults, and it is all done on a shoestring.
In terms of knowledge mobilization, with proper supportive funding for longer than four years it could be inspirational. It is based on work done by the John A. Hartford Foundation in the United States, which has funding of tens of millions of dollars annually. In comparison with how that is funded and where that work is done, we have been remarkably efficient.
The notion is that the network is funded purely for knowledge mobilization purposes. The concept is that good data and good evidence exist. We need to get it into the right hands and then mobilize, or, as my colleague says, ``What?'' ``So what?'' and ``Now what?'' We have the ``what'' in Canada; we have good research. We need the ``so what.'' It needs to be into the hands of the people, and that can include community care specialists, family, friends, lawyers, any intersections of older adults, and web-based learning.
Older adults are the largest new group of Internet users in Canada. There has been a wonderful work done in other countries and the NICE network is doing some learning with regard to how people absorb knowledge and then the ``Now what?'' how they mobilize and uptake. That is a fundamental and wonderful success story of which the federal government has been supportive. I strongly recommend that it continue to be supported and funded.
Ms. Desveaux: I recommend grassroots approaches. Publications are mailed to seniors who receive the Guaranteed Income Supplement and other initiatives. Perhaps information on elder abuse can go out in those types of publications. The working group is currently taking many initiatives and the message about what is happening is getting out there. Elder abuse is becoming widely known in the broader community. People are reporting incidents about isolated people in communities. In rural communities we have volunteer firemen, VON nurses and even the milkman going into homes. I have heard some very positive stories about individuals intervening from those spheres.
World Elder Abuse Awareness Day will be very helpful in getting that message out. An elderly woman sitting in her rocker in rural Ontario watching the news will hear about Elder Abuse Day. She may ask the VON nurse on her next visit what this is all about. She will start to connect the pieces and realize that perhaps it relates to her. This is the same message that was going out 30 years ago when woman started to realize that abuse was not normal behaviour. We have to get the message out and the work being done now is starting to accomplish that goal.
Ms. Watts: As I said at the beginning of my remarks, aging is not just something that we physiologically do; it is also a social movement. It is very akin to the disabilities movement or the feminist movement, and we are at that crux now. The notion of that discourse is very important with the variety of ways that it can be suggested and supported.
I want to talk about what that person could physically do. There is currently a paucity of access to justice. A woman can be supported in learning that she has rights and that elder abuse is happening, whether that consists of being yelled at or being threatened, or whether her mail is being kept away from her, which is a common form of neglect or specific isolation. She could be isolated because her phone lines have been cut by the family or caregiver. There are subtle forms of elder abuse. It could be that she is being physically abused, that she is given sedatives so that she is not awake. There is a broad scope of abuse.
If knowledge mobilization comes, what then? The reality of the circumstance is that if it were not for kind lawyers doing pro bono work there would be nowhere for the older woman in rural Ontario to go. It is highly unlikely that she can access funds to retain private counsel in those situations. She is probably cut off from her bank accounts. She probably does not know where to go. There may be a number that she can call in her area where she can get centralized services that might help her. That is wonderful, but in the end who will help her get those things back? She needs a lawyer. Where are the funds coming from? Our legal aid system does not currently support that, so we come back to: How does she get justice?
We need to be thinking about a federal scheme to support older adults and working collaboratively with organizations such as the Canadian Bar Associations. We must support legal aid clinics with specialized knowledge that support seniors, because in the end, if elders cannot access justice, they are still stuck.
The Chair: I want to thank both of you very much for your appearance this afternoon and for your knowledge and expertise. You can be assured that some of your many recommendations will make their way into a final report.
The committee adjourned.