Medical Assistance in Dying

On June 16, 2016, the federal government passed legislation to amend Canada’s Criminal Code and established a federal framework for Medical Assistance in Dying (MAID) for individuals who meet pre-defined eligibility criteria.

MAID, as defined by the Government of Canada, refers to:

  • The administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death.
  • The prescribing or providing by a medical practitioner 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.

As part of its efforts to implement a consistent approach to the MAID process in Ontario, the Ministry of Health and Long-Term Care (MOHLTC) has engaged the Centre for Effective Practice (CEP) to develop a resource to support clinicians (physicians and nurse practitioners) with the provision of MAID.

Medical Assistance in Dying Resource Download Français

Resource

The MAID resource summarizes the requirements outlined in the federal legislation and guidelines by various provincial regulatory colleges and presents them in a logical, sequential order to support clinicians with a patient request for MAID. The CEP’s resource also highlights key considerations and recommends processes for the provision of MAID by medical and nurse practitioners based on extensive consultations with key stakeholder organizations, regulatory bodies, and target end-users. It is intended to supplement, not circumvent, existing regulatory body requirements or institutional processes that have been implemented.

The CEP Medical Assistance in Dying Resource is comprised of the following sections:

  • Introduction
    Full pathway outlining process for the provision of MAID.
  • Section One: Patient Inquiry
    Addresses the patient’s inquiry about MAID and exploring the reasoning behind their request; details clinician requirements with respect to conscientious objections & patient referral.
  • Section Two: Assessment of Patient Eligibility for MAID
    Defines eligibility criteria & provides resources to support eligibility assessments; provides considerations when preparing for the provision of MAID.
  • Section Three: Provision of MAID
    Outlines key steps for the provision of MAID, certification of death, and reporting.
  • Section Four: Documentation Checklist
    Highlights significant steps of the MAID process and associated documentation.
  • Section Five: Supporting Material & References
    Includes a list of relevant resources, guidance documents, policy statements and tools for clinicians.

While this resource is based on the best available information to date, there may be gaps to the process that cannot be addressed at this time. Every effort will be made to update this resource as new information becomes available.

Definition of terms*

For the purpose of this resource in particular, the following terms are defined as:

  • Medical Practitioner — A physician who is entitled to practise medicine in Ontario.
  • Nurse Practitioner — A registered nurse who is entitled to practise as a nurse practitioner in Ontario.
  • Clinician — The medical or nurse practitioner that is overseeing the provision of MAID for an individual patient. This role may include, but is not limited to, receiving a patient request for MAID, conducting the first eligibility assessment, and administering or prescribing the drug protocol for the provision of MAID. It is recommended that this Clinician be responsible for ensuring that all relevant documentation is obtained and included in the patient’s medical record. In instances where the Clinician responsible for the provision of MAID is not the Most Responsible Provider (MRP) (e.g., in cases of conscientious objection and patient referral), the MRP will remain involved to direct coordination of care for the patient (excluding the provision of MAID).
  • Second Clinician — The medical or nurse practitioner that conducts the second, independent eligibility assessment of the patient. This role may also include administering or prescribing the drug protocol for the provision of MAID.

*The MRP and the Clinician OR Second Clinician may have overlapping roles and responsibilities or may be the same individual.

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Project Overview

The Medical Assistance in Dying resource is intended to support clinicians (physicians and nurse practitioners) with the provision of MAID and to facilitate a consistent approach to the process within Ontario. The provision of supporting resources, key considerations, and recommended suggestions for practice are all intended to address the need identified by clinicians to support the practicalities of implementing MAID in clinical practice

Development Process

The Medical Assistance in Dying resource was developed using the CEP’s integrated knowledge translation approach. This approach ensures that providers are engaged throughout development processes through the application of user-centered design methodology. Clinical leadership of the resource was provided by Dr. Sandy Buchman. Clinical experts, policy advisors, hospitals and faith-based organizations were also engaged to provide feedback on key processes and components relevant to Medical Assistance in Dying.

The Medical Assistance in Dying resource is one of several resources developed as part of the 2014 to 2017 Knowledge Translation in Primary Care Initiative. This multi-year initiative was a collaboration between the Centre for Effective Practice (CEP), Ontario College of Family Physicians (OCFP), and Nurse Practitioners’ Association of Ontario (NPAO). Funded by the Ministry of Health and Long-Term Care, this initiative supported primary care providers with the development of a series of clinical tools and health information resources. Learn more about the Knowledge Translation in Primary Care Initiative.

As part of this initiative, the CEP has developed a Medical Assistance in Dying resource for all providers in order to help clinicians understand the legislation and be able to act accordingly in practice.

Meet the Team

The project team conducted a comprehensive literature search, and developed guidance based on current legislation and policy frameworks in partnership with the clinical lead and working group. Health care providers and other stakeholders were also engaged throughout the development process.

Clinical Lead

Sandy Buchman BA, MD, CCFP, FCFP

sandy-headDr. Sandy Buchman is an associate professor in the Department of Family and Community Medicine at the University of Toronto and practices palliative medicine, providing home-based palliative and end-of-life care. He practiced comprehensive family medicine for many years with special interest in primary care, cancer care, palliative care, HIV/AIDS and global health – including volunteer experiences in South America and Africa. He is the education lead at the Temmy Latner Centre for Palliative Care, Mount Sinai Hospital. He was President of the College of Family Physicians of Canada in 2011 – 2012 and the Ontario College of Family Physicians in 2005 – 2006.

He received his MD degree from McMaster University and completed his Family Medicine Residency training at the University of Toronto.

Acknowledgements

For the development of this resource, we consulted with many stakeholder organizations and regulatory bodies, including:

  • Catholic Health Association of Ontario
  • Canadian Medical Association
  • Canadian Medical Protective Association
  • Central East LHIN – MAiD Working Group
  • College of Nurses of Ontario
  • College of Physicians and Surgeons of Ontario
  • Joint Centre for Bioethics
  • Nurse Practitioners’ Association of Ontario
  • Office of the Chief Coroner of Ontario
  • Ontario Medical Association
  • Ontario College of Family Physicians
  • Ontario College of Pharmacists
  • Ontario Hospital Association
  • Ontario Ministry of Health and Long-Term Care
  • Mount Sinai Support Services and Bridgepoint
  • Thunder Bay Hospital MAID Committee
  • Trillium Gift of Life Network
  • Clinical experts and target end-users

Thank you to all providers and stakeholders who participated in the development of this clinical resource.

Supporting Material

Supporting Material

Here are some additional resources and sources of information. These supporting materials are hosted by external organizations and we cannot guarantee the accuracy and accessibility of their links. The CEP will make every effort to keep these links up to date.

  1. College of Physicians and Surgeons of Ontario Policy Statement #4-16: Medical Assistance in Dying
    http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/medical-assistance-in-dying.pdf?ext=.pdf
  2. CPSO Fact Sheet: Ensuring Access to Care – Effective Referral
    http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/PAD-Effective-Referral-FactSheet.pdf
  3. Guidance on Nurses’ Roles in Medical Assistance in Dying
    http://www.cno.org/globalassets/docs/prac/41056-guidance-on-nurses-roles-in-maid-july-4-vfinal.pdf
  4. Clinician Aid A – Patient Request for Medical Assistance in Dying
    http://bit.ly/29Sovs0
  5. Clinician Aid B – (Primary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying Aid
    http://bit.ly/2a9M8Pf
  6. Clinician Aid C – (Secondary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying Aid
    http://bit.ly/2eyjexk
  7. NICE Capacity and Consent Tool
    http://www.nicenet.ca/files/NICE_Capacity_and_Consent_tool.pdf
  8. Aid to Capacity Evaluation (ACE)
    http://www.jcb.utoronto.ca/tools/documents/ace.pdf
  9. Assessment of Capacity to Consent to Treatment (ACCT): Challenges, the “ACCT” Approach, Future Directions
    https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3074108/
  10. College of Physicians and Surgeons of Ontario Policy Statement #3-15: Consent to Treatment
    http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/Consent-To-Treatment.pdf?ext=.pdf
  11. College Nurses of Ontario Practice Guideline: Consent
    http://www.cno.org/globalassets/docs/policy/41020_consent.pdf
  12. Assessing Vulnerability in a System for Physician-Assisted Death in Canada
    http://www.sacl.org/fileadmin/user_upload/CACL_Vulnerability_Assessment_Apr_8_2016_-_Final.compressed.pdf
  13. Justice Canada’s Legislative Background: Medical Assistance in Dying (Bill C-14, as Assented to on June 17, 2016)
    http://justice.gc.ca/eng/rp-pr/other-autre/adra-amsr/p2.html – sec14
  14. The Gold Standards Framework (GSF) Prognostic Indicator Guidance
    http://www.goldstandardsframework.org.uk/cd-content/uploads/files/General Files/Prognostic Indicator Guidance October 2011.pdf
  15. Supportive and Palliative Care Indicators Tool (SPICT)
    http://www.gov.scot/resource/doc/924/0111396.pdf
  16. Mississauga Halton Regional Hospice Palliative Care Early Identification and Prognostic Indicator Guide
    https://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=344053
  17. Murray SA, Kendall M, Boyd K, Sheikh A. Illness Trajectories and Palliative Care. BMJ. 2005;330(7498):1007-1011
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC557152/
  18. Department of Justice Canada: Medical Assistance in Dying Glossary
    http://www.justice.gc.ca/eng/cj-jp/ad-am/glos.html
  19. Ontario Medical Association: Physician Health Program
    http://php.oma.org/index.htm
  20. College of Physicians and Surgeons of Ontario Policy Statement #6-16: Planning for and Providing Quality End-of-Life Care
    http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/End-of-Life.pdf?ext=.pdf
  21. Trillium Gift of Life Network (TGLN): Public Reporting (List of Designated Facilities and Sites)
    http://www.giftoflife.on.ca/en/publicreporting.htm – donors-cal
  22. CPSO Drug Protocols – Member Login
    https://www.cpso.on.ca/Login.aspx
  23. Additional supporting materials and resources that may be useful for Clinicians:

  24. Canadian Nurses Protective Society: Medical Assistance in Dying: What Every Nurse Should Know
    http://cnps.ca/MAID
  25. College of Nurses of Ontario Medical Assistance in Dying – FAQS
    http://www.cno.org/en/trending-topics/medical-assistance-in-dying/medical-assistance-in-dying–faqs/
  26. College of Physicians and Surgeons of Ontario Policy Statement #4-16: Medical Assistance in Dying
    http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/medical-assistance-in-dying.pdf?ext=.pdf
  27. FAQ about the Vulnerable Persons Standard
    http://static1.squarespace.com/static/56bb84cb01dbae77f988b71a/t/56ec3f6d2eeb817a4988351d/1458323310
  28. Ontario College of Family Physicians: Medically-Assisted Dying
    http://ocfp.on.ca/tools/medically-assisted-dying
  29. Ontario College of Pharmacists: Medical Assistance in Dying: Guidance to Pharmacists and Pharmacy Technicians
    http://www.ocpinfo.com/library/practice-related/download/PhysicianAssistedDeath.pdf
  30. Trillium Gift of Life Network (TGLN): Routine Notification for Designated Hospitals FAQ
    https://www.giftoflife.on.ca/resources/pdf/Routine%20Notification.pdf
  31. Vulnerable Persons Standard
    http://static1.squarespace.com/static/56bb84cb01dbae77f988b71a/t/56e17c654d088e2c2003c978/1457618022701/VPSStandard-March9.pdf

References

  1. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) (formerly Bill C-14), 1st Sess, 42nd Leg, Canada, 2016 (assented to June 17, 2016).
  2.  College of Physicians & Surgeons of Ontario: Medical Assistance in Dying. 2016. Available from: http://www.cpso.on.ca/CPSO/media/documents/Policies/Policy-Items/medical-assistance-in-dying.pdf?ext=.pdf
  3. College of Nurses of Ontario: Guidance on Nurses’ Roles in Medical Assistance in Dying Available from: http://www.cno.org/globalassets/docs/prac/41056-guidance-on-nurses-roles-in-maid-july-4-vfinal.pdf
  4. Ontario College of Pharmacists: Medical Assistance in Dying: Guidance to Pharmacists & Pharmacy Technicians Available from: http://www.ocpinfo.com/library/practice-related/download/PhysicianAssistedDeath.pdf
  5. Branigan M. Desire for hastened death: exploring the emotions and the ethics. 2015. Curr Opin Support Palliat Care. 9(1):64-71.
  6. Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A
  7. Trillium Gift of Life Network Act, R.S.O. 1990

Copyright & Disclaimer

CEP fully supports the use of the Medical Assistance in Dying Resource by providers, educators, decision-makers and others. Please read the following information prior to use of the resource to ensure appropriate permission is sought and appropriate citation is used.

Creative Commons License

Creative CommonsThe Medical Assistance in Dying resource is a product of the Centre for Effective Practice.  Permission to use, copy and distribute this material for all non-commercial and research purposes is granted, provided that all copies, modifications, and distributions contain full reproductions of this Creative Commons License and the following Disclaimer along with appropriate citation.  Use of the Medical Assistance in Dying resource for commercial purposes or any modifications of the tool are subject to charge and use must be negotiated with Centre for Effective Practice (Email: info@effectivepractice.org)

For statistical and bibliographic purposes, please notify the Centre for Effective Practice (info@effectivepractice.org) of any use or reprinting of the resource.

Please use this citation when referencing the resource: Reprinted with Permission from Centre for Effective Practice (Novembewr 2016). Medical Assistance in Dying. Toronto: Centre for Effective Practice.

Disclaimer

Medical Assistance in Dying (the “Resource”) contains links to websites and other external resources (“Third Party Resources”) that are operated by and/or created by third party organizations.  These third party organizations are solely responsible for the information contained in, and the operation of (as applicable), their respective third Party Resource(s).

This resource was developed for licensed health care professionals in Ontario as a guide only and does not constitute medical or other professional advice. Providers and other health care professionals are required to exercise their own clinical judgment in using this resource.

Neither the Centre for Effective Practice (“CEP”), Ontario College of Family Physicians, Nurse Practitioners’ Association of Ontario, Government of Ontario, the contributors to this resource, nor any of their respective agents, appointees, directors, officers, employees, contractors, members or volunteers: (i) are providing medical, diagnostic or treatment services through this resource; (ii) to the extent permitted by applicable law, accept any responsibility for the use or misuse of this resource by any individual including but not limited to, providers, or entity, including for any loss, damage or injury (including death) arising from or in connection with the use of this resource, in whole or in part; or (iii) give or make any representation, warranty or endorsement of any of the Third Party Resources, that are owned or operated by third parties, including any information or advice contained therein.