Medical Assistance in Dying


Introduction

On June 17, 2016, the federal government passed Bill C-14 which outlines requirements that patients must meet to be eligible to receive medical assistance in dying, and establishes safeguards that a doctor or nurse practitioner must follow to legally provide medical assistance in dying. Bill C-14 amended the Criminal Code and made related amendments to other federal acts with respect to medical assistance in dying.

On May 10, 2017, Ontario's Medical Assistance in Dying Statute Law Amendment Act, 2017, received Royal Assent and came into force. It made amendments to various Ontario statutes to address areas relevant to medical assistance in dying that fall under provincial jurisdiction. The legislative amendments provide greater clarity and legal protection for health care providers (including institutions and clinicians) as well as patients navigating medical assistance in dying. The legislative amendments also established a new role for the coroner in overseeing medically assisted deaths.

On November 1, 2018, federal regulations under the Criminal Code, establishing a pan-Canadian medical assistance in dying monitoring regime, came into force. The purpose of the federal monitoring regime is to collect and analyze data, identify and monitor trends, support public accountability, transparency and the protection of the vulnerable. Under the federal regulations, any written request for medical assistance in dying received on or after November 1, 2018, may trigger new reporting requirements for health care providers. Please see the Federal Regulations and Ontario's Hybrid Approach to the Reporting Requirements section below for more information.

Health care providers, including physicians, nurses and pharmacists, should refer to their regulatory colleges for additional professional guidance related to the provision of medical assistance in dying.

For insured persons, the drugs and services required for medical assistance in dying are normally available at no cost to the patient.

Information on medical assistance in dying:

Medical Assistance in Dying

The term Medical Assistance in Dying, describes:

  • the administering by a physician or nurse practitioner of a substance to a person, at their request, that causes their death; or
  • the prescribing or providing by a physician or nurse practitioner of a substance to a person at their request, so that they may self-administer the substance and in doing so cause their own death.

Patient Eligibility

Federal legislation creates a framework for medical assistance in dying across Canada, including establishing eligibility criteria. The eligibility requirements are that the patient must:

  • be 18 years or older,
  • be capable of making health care decisions,
  • have a grievous and irremediable medical condition, which means:
    • the patient has a serious and incurable illness, disease or disability, and
    • the patient is in an advanced state of irreversible decline in capabilities, and
    • the patient is enduring physical or psychological suffering, caused by the medical condition or the state of decline, that is intolerable to the person, and
    • the patient's natural death has become reasonably foreseeable;
  • be making a voluntary request;
  • provide informed consent to medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.

Individuals may access medical assistance in dying in Ontario if they are eligible or, but for any applicable minimum period of residence or waiting period, would be eligible for health services funded by a government in Canada. Canadian patients should speak with their clinician to determine steps needed to access medical assistance in dying in a province or territory that is not their primary residence.

Federal MAID legislation requires the federal government to initiate independent reviews of issues relating to requests by mature minors, those with only mental health conditions, and advance requests for medical assistance in dying.

In December 2016, the federal government requested the Council of Canadian Academies (CCA) to undertake the independent reviews and table the resulting reports in Parliament by December 2018. On April 27, 2017 the CCA announced the appointment of the Expert Panel on Medical Assistance in Dying, chaired by the Honourable Marie Deschamps and comprised of 43 individuals from Canada and abroad. To effectively address the three topics, the Expert Panel was organized into three working groups.

Patient Requests and Assessments

A patient should talk to a physician or nurse practitioner about options for treatment, which may include medical assistance in dying, palliative care or other end-of-life care options. To make a formal request for medical assistance in dying, the patient, if able, must fill out a written request, witnessed by two independent witnesses. The Ministry of Health and Long-Term Care has created a voluntary patient request form that can be used.

The federal legislation requires that the witnesses be at least 18 years of age, and be able to understand the nature of the request for medical assistance in dying. Witnesses must not:

  • know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death;
  • be an owner or operator of any health care facility at which the person making the request is being treated or any facility in which that person resides;
  • be directly involved in providing health care services to the person making the request; or
  • directly provide personal care to the person making the request.

Two independent physicians or nurse practitioners must confirm that a patient meets the eligibility requirements, and, in most cases, medical assistance in dying cannot be provided until at least 10 days have passed since the patient made the written request for it. In some cases, if death or loss of capacity is imminent, the physicians or nurse practitioners, who confirmed the patient's eligibility, may determine that a shorter waiting period is appropriate.

Under the federal legislation, practitioners will be considered to be independent if they:

  • are not a mentor to the other practitioner or responsible for supervising their work;
  • do not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death, other than standard compensation for their services relating to the request; or
  • do not know or believe that they are connected to the other practitioner or to the person making the request in any other way that would affect their objectivity.

The patient must understand that it is his/her right to have a change of mind and can withdraw a request for medical assistance in dying at any time in the process.

If a patient is found not to meet the eligibility requirements by their doctor or nurse practitioner, the patient can seek a second medical opinion.

Accessing Medical Assistance in Dying: How to Contact the MAID Care Co-ordination Service

On May 31, 2017, Ontario established a care co-ordination service to help patients and clinicians access information and supports for medical assistance in dying and other end-of-life options. Through the care co-ordination service, patients and their caregivers can receive information about end-of-life options in Ontario, including information on hospice care, other palliative care options in their communities, and medical assistance in dying. Patients and caregivers can also call the care co-ordination service to request to be connected to a doctor or nurse practitioner who can provide medical assistance in dying services, such as eligibility assessments.

Doctors or nurse practitioners who are unable or unwilling to provide medical assistance in dying can also contact the care co-ordination service in order to refer their patients to doctors or nurse practitioners who can provide these services. Pharmacists who are unable or unwilling to dispense medical assistance in dying drugs can also contact the care co-ordination service to make a referral.

This service also supports patient access to medical assistance in dying by helping clinicians connect with a:

  • Doctor or nurse practitioner who can provide the second assessment that is needed to confirm that a patient meets all the eligibility criteria as set out in the federal legislation.
  • Community pharmacist who will dispense the drugs needed for medical assistance in dying.
  • Doctor or nurse practitioner who will prescribe or administer the drugs required for medical assistance in dying, if needed.

The care co-ordination service information line is available 24 hours a day, 7 days a week and may be reached toll free at 1-866-286-4023. Referral services are available Monday to Friday 9 am – 5 pm EST in English and French (translations for other languages can also be requested). TTY services are also available at 1-844-953-3350.

Advanced Medical Directives, Living Wills and Substitute Decision-Makers

Because the federal legislation requires the patient to expressly consent to the provision of medical assistance in dying immediately before it is provided, advance medical directives are not allowed. However, the federal legislation requires the federal government to study the feasibility and appropriateness of allowing advance medical directives for medical assistance in dying.

Family members or friends cannot act as substitute decision-makers for medical assistance in dying, and have no legal authority to consent to or authorize medical assistance in dying on behalf of a patient.

Administering Medical Assistance in Dying

The federal legislation allows:

  • a physician or nurse practitioner to administer a substance directly to the patient, such as through a drug injection; or
  • a physician or nurse practitioner to prescribe or provide a substance to the person to self-administer, such as by orally ingesting drugs.

An eligible patient can request either of the options noted above. The drugs are normally provided at no cost to the patient.

Physicians and nurse practitioners registered in Ontario can provide medical assistance in dying, either as the primary clinician or as the secondary/consulting clinician (who provides a written opinion confirming the patient satisfies all the eligibility requirements for medical assistance in dying). Pharmacists will dispense the drugs used to provide medical assistance in dying.

Other health care professionals (e.g., nurses, social workers) can support a physician or nurse practitioner providing medical assistance in dying. The federal legislation also allows them to provide information to a person on how medical assistance in dying is permitted in Canada. The federal legislation allows an individual, such as a family member, to help a patient self-administer the drugs, provided that the patient explicitly requests the individual's help.

The patient must confirm consent immediately before medical assistance in dying drugs are administered to him or her by the clinician, or before a self-administered prescription is written and provided to the patient.

In addition to complying with federal and provincial medical assistance in dying legislation in providing (or assisting in the provision of) medical assistance in dying, health professionals in Ontario must comply with any additional professional obligations required by their health regulatory colleges.

Physicians, nurse practitioners and those who assist them, as well as institutions that participate in the lawful provision of medical assistance in dying are protected from civil liability, except in cases of negligence, under Ontario's legislation.

Family Members, Caregivers, Friends

Patients are encouraged to talk with their family and/or caregivers about their choice to pursue medical assistance in dying.

There is no formal notification process for families when an individual requests or is provided with medical assistance in dying. Family members, friends, and/or personal caregivers of individuals who are considering or have requested medical assistance in dying have no "right", legal or otherwise, to intervene.

Under certain conditions the federal legislation allows an individual, such as a family member, to help a patient self-administer the drugs, provided that the patient explicitly requests the individual's help.

Family members, caregivers or friends looking for information or help to facilitate access to medical assistance in dying may call the care coordination service toll free at 1-866-286-4023. The care coordination service information line is available 24 hours a day, 7 days a week. Referral services are available Monday to Friday 9 am – 5 pm EST in English and French (translations for other languages can also be requested). TTY services are also available at 1-844-953-3350.

Dispensing Drugs

Eligible patients will not have to cover the cost of drugs used to provide medical assistance in dying. In the hospital setting, drugs to administer medical assistance in dying would be dispensed by the inpatient pharmacy and covered by the hospital. For the administration of medical assistance in dying outside the hospital, such as a patient self-administering the drugs in their home, drugs would be dispensed through community pharmacies at no charge to the patient.

Under federal legislation, clinicians must inform the pharmacist that the prescription is intended for medical assistance in dying before a pharmacist dispenses the prescription. Clinicians should make arrangements with pharmacies as early as possible to avoid delays in processing a prescription for medical assistance in dying.

As with any unused medication, medical assistance in dying drugs should be disposed of according to existing protocols and programs that assist people in disposing of unused medications. Many pharmacies in Ontario are part of the Return Program where they accept and safely dispose unused medications.

Clinicians can obtain information on medical assistance in dying prescribing protocols from their respective regulatory college.

Clinicians or patients seeking assistance in connecting with a community pharmacist who will dispense the drugs needed for medical assistance in dying may call the care co-ordination service toll free at 1-866-286-4023 or TTY 844-953-3350.

Accommodating Patients

The federal legislation requires that, if a patient has difficulty communicating, physicians and nurse practitioners take all necessary measures to provide a reliable means by which the patient can understand the information provided to him/her and communicate his/her decision with respect to medical assistance in dying.

Willing clinicians are permitted to use telemedicine to assess a patient's request for medical assistance in dying, as long as any care provided through telemedicine meets the requirements set out in federal legislation as well as all of the standards and expectations that apply to care provided in person. This will enable better accessibility to medical assistance in dying services for individuals living in rural/remote areas with limited access to health care services.

Where Medical Assistance in Dying Can Take Place

Patients can request access to medical assistance in dying from their clinicians whether they are in hospital, long-term care home, hospice or palliative care facility, or in their own homes.

Institutions that do not allow the provision of medical assistance in dying, or that have limits on how medical assistance in dying may be provided in the institution, are encouraged to make this information available to the public.

Regardless of any institutional policies with respect to medical assistance in dying, clinicians who work in institutions must meet the professional referral obligations established by their respective regulatory colleges. Institutions are encouraged to develop policies with respect to medical assistance in dying in this context.

Conscientious Objection and Obligations to Patients

In Ontario, health regulatory colleges are responsible for regulating their respective professions in the public interest. In doing so, colleges may establish policies and standards that their members must comply with, including policies and standards regarding medical assistance in dying.

  • The College of Physicians and Surgeons of Ontario requires that when physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another healthcare provider must be provided to the patient. An effective referral means "a referral made in good faith, to a non-objecting, available, and accessible physician, other health care professional, or agency." Referrals must be made in a timely manner.
  • Obligations to patients by nurses/nurse practitioners and pharmacists have been established by their respective regulatory colleges as part of existing codes of ethics.
  • Clinicians who are unwilling to provide medical assistance in dying can either make a referral using their own professional networks or institutional policies, or they may call the care co-ordination service at 1-866-286-4023 for support in meeting any referral requirements. The care co-ordination service information line is available 24 hours a day, 7 days a week. Referral services are available Monday to Friday 9 am – 5 pm EST in English and French (translations for other languages can also be requested). TTY services are also available at 1-844-953-3350.
  • If patients have questions about their clinician's professional obligations, the patient can contact the applicable regulatory college.

Clinicians must meet the professional obligations established by their respective regulatory colleges. Institutions are encouraged to develop policies with respect to medical assistance in dying in this context.

Institutions are encouraged to inform patients/residents of any institutional position on medical assistance in dying, including any and all limits on allowing its provision, so patients can make informed choices about their care options.

Monitoring Medical Assistance in Dying

Ontario has provided voluntary, standardized clinician aids that reflect the requirements set out in the federal legislation. Physicians and nurse practitioners are encouraged to complete the clinician aids in addition to their usual medical record-keeping requirements, as outlined by their regulatory colleges, and keep them on file. These clinician aids may assist physicians and nurse practitioners to prepare for reports and reviews that may be required in the future.

Reporting Deaths from Medical Assistance in Dying

Under Ontario law, physicians and nurse practitioners who provide medical assistance in dying are required to notify the coroner of the death, and provide the coroner with the facts and circumstances of the death. Once a death is reported, the coroner will determine whether it is appropriate to investigate the death. Each case is different, and the coroner cannot determine in advance of any death whether an investigation is warranted.

If the coroner is of the opinion that the death ought to be investigated, and investigates the death, the coroner is required to complete and sign the medical certificate of death. However, if the coroner is of the opinion that the death does not require an investigation, then, in accordance with applicable law, the physician or nurse practitioner is required to complete and sign the medical certificate of death.

Clinicians will need to work with the coroner's office to provide the information the office needs to make the process as efficient, effective and appropriate as possible. Clinicians should refer to the Office of the Chief Coroner's Process Overview and Checklist to better understand the process when reporting a MAID death and the pieces of information and documentation frequently requested by the Office of the Chief Coroner.

Patients who have chosen to self-administer medical assistance in dying are encouraged to share their plans and the contact information for their attending clinician with a family member/s or friend/s to help ensure authorities are aware that their death was planned. In the event of an investigation, the coroner will only obtain information necessary to fulfill their duties.

As of November 1, 2018, the Office of the Chief Coroner for Ontario will be implementing a more structured approach to respond to concerns regarding compliance with statutory requirements, regulations, and/or regulatory college policies on medical assistance in dying. In the interest of openness and transparency, the Office of the Chief Coroner has published a communication informing practitioners of the updated approach to oversight of medical assistance in dying, which their Office will follow, effective November 1, 2018.

For questions about the coroner's investigations process, contact occ.inquiries@ontario.ca or 1-877-991-9959.

Federal Regulations and Ontario's Hybrid Approach to the Reporting Requirements

New federal reporting requirements (i.e. federal Minister of Health regulations) for medical assistance in dying are in effect as of November 1, 2018. Any written request for medical assistance in dying received on or after November 1, 2018, may trigger reporting requirements under the new regulations.

As set out in the federal regulations, the following health care providers are required to report:

  • Physicians or nurse practitioners who receive a patient's written request for medical assistance in dying and encounter one of the following six scenarios:
    1. Medical assistance in dying was provided by administering a substance to a patient.
    2. Medical assistance in dying was provided by prescribing or providing a substance for self-administration by the patient.
    3. A patient was referred to another practitioner or a care coordination service, or a transfer of care occurred as a result of the request.
    4. A patient was found to be ineligible for medical assistance in dying.
    5. The clinician becomes aware that the patient has withdrawn their request for medical assistance in dying.
    6. The clinician becomes aware that the patient has died from a cause other than medical assistance in dying.
  • Pharmacists who dispense a substance in connection with the provision of medical assistance in dying.

To minimize the reporting burden on clinicians, Ontario has developed a hybrid approach to work with the federal reporting regulations:

  1. In cases where a medically assisted death has occurred (clinician and self-administered cases), physicians and nurse practitioners are required to report to the Chief Coroner for Ontario immediately after confirming or becoming aware that the patient has died.
    • The Office of the Chief Coroner will collect information from physicians and nurse practitioners on all medically assisted deaths, and will report to the federal Minister of Health (i.e. Heath Canada) on their behalf.
    • This will maintain the status quo for clinicians, who were already required under the Coroners Act to report to the Office of the Chief Coroner for any MAID death.
  2. In all cases where a request was made, but a medically assisted death has not occurred, physicians and nurse practitioners are required to report to Health Canada via the Canadian MAID Data Collection Portal.
    • This includes cases where a written request was received, but a MAID death did not occur (e.g., the clinician who received the written request found the patient to be ineligible, the patient was referred, the patient withdrew the request for MAID, or the patient died from a cause other than MAID). Under these scenarios, the practitioner has up to 30 calendar days to file a report. The 30 days starts after one of those four events, not as soon as the written request is submitted to the practitioner. If none of the aforementioned events happens within 90 calendar days of the practitioner receiving the written request, the practitioner is not required to report to Health Canada.
    • This also includes cases where a physician or nurse practitioner has provided a prescription for self-administered medical assistance in dying, but a medically assisted death has not occurred (e.g., the patient died from a cause other than MAID, the patient is still alive, or the outcome is unknown). Under these scenarios, the practitioner must report no earlier than 90 days and no later than 120 days after the prescription or substance is provided. However, if the practitioner becomes aware of the patient's death from a cause other than MAID in less than 90 days, the practitioner may report to Health Canada before the 90th day. If the practitioner becomes aware of the patient's death from MAID in less than 90 days, the practitioner must report to the Chief Coroner for Ontario immediately after confirming or becoming aware that the patient has died.
  3. All pharmacists who have dispensed a substance in connection with the provision of medical assistance in dying are required to report to Health Canada via the Canadian MAID Data Collection Portal within 30 days after the day of dispensing.

The following table provides scenarios where a written request is received and medical assistance in dying has been provided.

Scenario Whom to Report to Deadline to report
Clinician-Administered MAID
You provided MAID by administering a substance to a patient
Chief Coroner for Ontario Immediately after confirming the patient has died.
Patient-Administered MAID
You provided MAID by prescribing or providing a substance for self-administration by the patient
Chief Coroner for Ontario Immediately after becoming aware the patient has died.

The following table provides scenarios where a written request is received and a MAID death has not occurred.

Scenario Whom to Report to Deadline to report Related rules
Patient Referred
You referred a patient to another practitioner or a care coordination service or transferred their care as a result of the request
Health Canada Within 30 days after the day of referral/ transfer.
  • You do not need to report if you refer or transfer a patient more than 90 days after the day you receive the written request.
  • If you report with respect to a referral or transfer of care, you are not required to report again for the same written request unless you later provide MAID.
Patient Ineligible
You found a patient to be ineligible for MAID
Health Canada Within 30 days after the day ineligibility is determined.
  • You do not need to report if you find a patient ineligible more than 90 days after the day you receive the written request.
  • If you report on a finding of ineligibility, you are not required to report again for the same written request unless you later provide MAID.
Request Withdrawn
You became aware that the patient withdrew the request for MAID
Health Canada Within 30 days after the day you became aware of the withdrawal.
  • You do not need to report if you become aware, more than 90 days after the day you receive the written request, that a patient has withdrawn their request.
  • If you report on the withdrawal of a request, you are not required to report again for the same written request unless you later provide MAID.
  • If the patient has not contacted you after the initial written request, you are not required to actively seek out information about whether the patient has withdrawn the request, whether or not you have assessed them. In such a situation, you do not need to report.
Death – Other Cause
You became aware of the death of the patient from a cause other than MAID
Health Canada Within 30 days after the day you became aware of the patient's death.
  • You do not need to report if you become aware, more than 90 days after the day you receive the written request, that a patient has died of a cause other than MAID.
  • If the patient has not contacted you after the initial written request, you are not required to actively seek out information about whether the patient has died of a cause other than MAID, whether or not you have assessed them. In such a situation, you do not need to report.
Self-Administered MAID Prescription Provided – No MAID Death
(Patient Alive, Died from Another Cause, or Outcome is Unknown)
Health Canada No earlier than 90 days and no later than 120 days after the substance was prescribed. If the practitioner becomes aware of the patient's death from any cause in <90 days, the practitioner may report to Health Canada before the 90th day. N/A

Under Ontario's hybrid approach, there will be duplicative reporting for only a small fraction of self-administered medical assistance in dying cases that result in a medically assisted death. Duplicative reporting would only occur if a medically assisted death occurs after the 90th day from when the substance for self-administration was prescribed and the physician or nurse practitioner had already reported to Health Canada. In this scenario, a physician or nurse practitioner would be required to report to Health Canada between the 90-120 day period stipulated in federal regulations, and then to the Office of the Chief Coroner immediately after becoming aware of the self-administered medically assisted death. Duplicative reporting is expected to be minimal.

The requirement to provide information for monitoring purposes is triggered by the receipt of a written request for medical assistance in dying. According to Health Canada, a patient's written request may take any form including a text message, an e-mail, or Clinician Aid A. It must, however, be more than an inquiry or a request for information about medical assistance in dying. The request does not have to be in the format required by the Criminal Code as a safeguard when medical assistance in dying is provided (i.e., duly signed, dated and witnessed) to require reporting.

In cases of a medically assisted death, only the clinician who provides medical assistance in dying must report to the Coroner. If the first assessor is not the clinician providing medical assistance in dying, they may need to report a referral to Health Canada.

The above summary was provided for informational purposes only. For more detailed information about the federal reporting requirements for medical assistance in dying, please refer to the federal regulations and/or Health Canada's website. For questions about Ontario's hybrid reporting approach, contact endoflifedecisions@ontario.ca.

Funding for Medical Assistance in Dying Services

Physician and nurse practitioner activities for medical assistance in dying are funded through existing OHIP billing codes for physician services, and salaried contracts for nurse practitioners.

Existing compensation mechanisms are also employed to compensate pharmacists and other health care professionals involved in the provision of medical assistance in dying.

The cost of drugs for all eligible patients are also covered for both clinician-administered and patient self-administered medical assistance in dying, in any location.

For More Information

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