Medical Assistance in Dying (MAID): Ontario

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Amendments made to Canada’s Criminal Code, establish a federal framework for the lawful provision of Medical Assistance in Dying (MAID).1 Ontario has also passed legislation with respect to MAID.8

MAID, as denoted by federal legislation 1, refers to:

Federal MAID legislation1 enacted through federal Bill C-14, requires that:

  • The administering by a medical practitioner or nurse practitioner (NP) of a substance to a person, at their request, that causes their death; or
  • 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.

The Ontario Ministry of Health and the Ministry of Long-Term Care (the Ministry) engaged the Centre for Effective Practice (CEP) to develop a resource to support Clinicians in the provision of MAID and to facilitate a consistent approach for the implementation of MAID within Ontario.

This resource highlights key considerations and recommends processes for the provision of MAID by Clinicians based on extensive consultations with key stakeholder organizations and regulatory bodies. It is intended to supplement, not circumvent, existing legal requirements, regulatory body requirements, or institutional processes that have been established. While this resource is based on the best available information, there may be gaps in the process that cannot be addressed at this time. Every effort will be made to incorporate updates as new information becomes available.

Ontario’s Bill 84, the Medical Assistance in Dying Statue Law Amendment Act, 2017

  • Requiring the Coroner to be notified of all MAID deaths;
  • Requiring that certain information be disclosed by Clinicians, so that the Coroner is able to properly exercise discretion in determining whether to investigate;
  • Clarifying that the existing requirement under the Coroners Act to investigate any death from any cause other than disease does not apply to MAID;
  • Clarifying when the Coroner is required to complete medical certificates of death for MAID deaths; and
  • Requiring a process be in place to review the Coroner’s role after two years.
  • Regulation 1094 was amended to provide clarity for Coroners regarding the completion of medical certificates of death. The regulation stipulates that a Coroner must complete a medical certificate of death in MAID cases only when he or she has determined that the death ought to be investigated.
  • For all other MAID deaths, if a Coroner is of the opinion that the death does not require an investigation, the most responsible Clinician must complete and sign the medical certificate of death and indicate the underlying illness, disease or disability as the cause of death. In addition to Bill 84, in April 2017, a regulation under the Nursing Act, 1991, was amended to enable nurse practitioners to prescribe controlled drugs and substances, including those used in the provision of MAID.
Definition of terms

Medical Practitioner: A physician who is entitled to practise medicine in Ontario.

Clinician: For the purposes of this resource, the term Clinician refers to 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). For the purposes of this resource, the term Second Clinician refers to 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.

Nurse Practitioner: A registered nurse who is entitled to practise as a nurse practitioner in Ontario.

The Care Coordination Services (CCS): supports patients, family/caregivers acting on patients’ behalves, and Clinicians by providing information about end-of-life options, including MAID, and by assisting in making referrals for MAID services.
• Patients and family/caregivers acting on their behalf may access the service to make requests to be connected to a Clinician who is willing to provide MAID services, including eligibility assessments.
• For Clinicians who are unwilling or unable to provide MAID, this service can assist in referring their patients to Clinicians who are willing to provide MAID services.
• This service will also support patient access to MAID by helping Clinicians connect with a:
• Clinician who can provide the second assessment that is needed to confirm that a patient meets all the eligibility criteria as required by the federal MAID legislation;
• Community pharmacist that will dispense the drugs needed for MAID; and
• Clinician that will prescribe or administer the drugs required for MAID, if needed.

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

Full Pathway for MAiD

Documentation Checklist

Please see Documentation Checklist for a list of documentation that should be included in the patient’s medical record. These records should be on-hand and accessible to support an efficient and effective investigation by the Office of the Chief Coroner.

Patient Inquiry

Patient Inquires about MAID

A patient’s inquiry about MAID can take many forms:5

  • An explicit request for MAID;
  • A general inquiry of all available options to reduce suffering and expedite death (including MAID);
  • An expressed desire to end their life with the assistance of a medical or nurse practitioner.

Advance Medical Directive

A patient must be capable of consenting to MAID immediately before it is provided. For this reason, a person cannot consent to MAID through a living will or advance medical directive. Similarly, a substitute decision-maker cannot consent to MAID on behalf of a patient. Family/caregivers or any other individual do not have the legal authority to consent to or authorize MAID on behalf of a patient.

Conscientious Objections and Patient Referral

Clinicians with conscientious objections must respectfully inform their patients that they are unable to provide MAID and refer patients to another medical or nurse practitioner, institution, or agency that is willing to facilitate the provision of MAID, such as the Ministry’s CCS. The referral must be made in a timely manner to ensure that patients are not exposed to unnecessary delays or adverse clinical outcomes (e.g., decline in capacity). Irrespective of a patient’s desire to explore MAID through another non-objecting Clinician, institution, or agency (e.g., CCS), Clinicians must continue to provide ongoing care (excluding the provision of MAID) and not abandon the patient.2, 3, 4

Clinicians must comply with the requirements, policies, and guidelines set out by their respective regulatory college regarding conscientious objection and patient referral.

Clinicians are required to adhere to additional directives outlined by their institution or agency (e.g., institutions may implement specific processes and policies to facilitate patient referral and to ensure access to care).

Clinicians who choose not to provide MAID can either make a referral through their own professional networks or through the Ministry’s CCS.

The Ministry has created the CCS to support referrals by Clinicians, patients and family caregivers acting on their behalf. The CCS information line [1-866-286-4023] is available 24/7. Referral services are available Monday – Friday 9am – 5pm ET, with voicemail available after hours. Both the information line and referral services are available in English and French (translation for other languages can be requested) and TTY is available at 1-844-953-3350.

Patient Submits Formal Written Request

Patients must submit a formal written request for MAID, signed and dated in the presence of two independent‡ witnesses. The formal written request can only be signed and dated by the patient after they have been informed by the Clinician that they have a grievous and irremediable medical condition.

  • For patients who are unable to write, the formal request can be transcribed
  • For patients who are unable to sign and date the request, another person — who is at least 18 years of age, who understands the nature of the request for MAID and who does not know or believe that they are a beneficiary under the will of the patient, or a recipient, in any other way, of a financial or other material benefit resulting from that patient’s death — may do so in the patient’s presence, on the patient’s behalf and under the patient’s expressed direction1

The patient’s formal written request must be signed and dated before two independent witnesses, who then must also sign and date the request. To meet the legal conditions for independent witness, the following criteria must be met:1

  • Person 18 years of age or older;
  • Understands the nature of the request for MAID;
  • Must not know or believe that they are a beneficiary under the will of the patient making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that patient’s death;
  • Must not be an owner or operator of any health care facility at which the patient making the request is being treated or any facility in which the patient resides;
  • Must not be directly involved in providing health care services to the patient making the request; and
  • Must not be directly providing personal care to the patient making the request

The Ministry has created Clinician Aids to record the patient’s request and the results of the eligibility assessments:

Discussion to understand motivation behind patient’s inquiry about MAID

An expressed desire to end one’s life through MAID requires a careful exploration to understand the patient’s suffering, as well as inducements that may arise from psychosocial or non-medical conditions and circumstances. If psychosocial factors (e.g., grief, loneliness, stigma, shame), or social conditions (e.g., lack of needed supports for the patient and caregivers) are motivating the patient’s request, efforts should be made to alleviate these concerns.
This is an opportunity for the Clinician to:

  • Assess the patient’s motivations for the request;
  • Discuss the patient’s concerns and unmet needs;
  • Explore with the patient all alternate treatment options (e.g., comfort/palliative care, pain/symptom control, psychological support) including MAID.

Patients are not required to undergo any procedure or treatment that is not acceptable to them.

Note: Reporting is always required when MAID is provided, regardless of the time that has passed since the receipt of the written request. For all other outcomes, reporting is only required if the outcome occurs within 90 days.

Federal reporting requirements

Federal MAID legislation1 enacted through federal Bill C-14, requires that:

  • Physicians, nurse practitioners, and pharmacists provide information for the purpose of monitoring MAID; and
  • The federal Minister of Health to make regulations to establish a pan-Canadian monitoring regime for MAID.

The federal reporting requirements capture not only MAID deaths, but also written requests for MAID, even if a MAID death never occurs (e.g. if the patient dies beforehand, if they were deemed ineligible, if they change their
mind, etc.).

A patient’s written request for MAID may take any form including a text message or an e-mail. The request does not have to be in the format required by the Criminal Code as a safeguard when MAID is provided (i.e. duly signed, dated and witnessed) to require reporting. It must, however, be an explicit request for MAID.

Ontario has taken on a hybrid approach to federal reporting, in that:

  • All Clinician-administered and self-administered MAID cases that result indeath are reported to the Office of the Chief Coroner.
  • All other reporting requirements that do not result in a MAID death are reported to Health Canada.

Clinicians will report to Health Canada via the Canadian MAID Data Collection Portal in the following situations where a written request for MAID has been received.

  • Patient is assessed as ineligible
  • Patient is referred to another practitioner or care coordination service
  • Patient dies from a cause other than MAID
  • Patient withdraws request for MAID

Clinicians must comply with the federal reporting requirements, which are in effect as of November 1, 2018. Reporting timelines are indicated in the flowchart above.

Supporting resources
  • Resources outlining the deadlines and rules relating to the federal reporting requirements can be accessed here
  • Health Canada’s Canadian MAID Data Collection Portal: Access the Portal

Assessment of Patient Eligibility for MAID

Competent Adult and Assessing Capacity

  • Federal legislation outlines that the patient must be at least 18 years of age and capable of making decisions with respect to their health to qualify to receive MAID.1
  • As capacity is specific to time and treatment:
    • The patient’s capacity must be assessed specifically for consenting to MAID; and
    • The patient must be capable immediately before MAID is provided.

The requirements for capacity to undergo MAID are the same as those for any health care treatment. The use of existing procedures for capacity assessments are encouraged.2

Two-part question to assess capacity: 6

  1. Is the patient able to understand the information relevant to deciding to consent, or to refusing to consent, to MAID?
  2. Is the patient able to consider and appreciate the reasonably foreseeable consequences of consenting or not consenting to MAID?
The following resources may be helpful to Clinicians when assessing capacity:

Voluntary Request and Informed Consent to MAID

The patient’s request for MAID must be voluntary and not result from external pressure. 1, 2, 3

Reasonable measures should be taken to assess that the patient’s decision has been made freely, without coercion or undue influence from family members, health care providers, or others. Patient must provide informed consent to receive MAID, after having been informed of alternate care options available to alleviate suffering, including palliative care.1

In order for consent to be informed, the patient must understand the six components of informed consent, as outlined in the Health Care Consent Act, 1996:6

  • The nature of the treatment;
  • The expected benefits of the treatment;
  • The material risks of the treatment;
  • The material side effects of the treatment;
  • Alternative courses of action; and
  • The likely consequences of not having the treatment.

The patient must understand that consent can be withdrawn at any time before undergoing MAID, without negative consequences on the Clinician-patient relationship or on the care provided to the patient.

Clinicians should consider the following to determine if their patient meets the criteria for informed consent. The patient:

  • Consents specifically to MAID and understands the certainty of death upon being given or taking the lethal medication;2
  • Is fully informed of the process for the provision of MAID, including time, place, and method of administration;
  • Understands their health status, diagnosis, prognosis, and likelihood of death upon taking the lethal medication;
  • Is aware of potential complications related to the provision of MAID, including medication failure;
  • Is fully informed of alternative treatments and courses of action, such as: comfort, palliative, and hospice care, pain and symptom control, and psychological or spiritual counselling;
  • Is informed that upon death, their body may be transferred by the Office of the Chief Coroner for examination. The extent of the investigation by the coroner cannot be predicted in advance and, while unlikely, may include an autopsy. If the Coroner determines that the death has to be investigated and investigates, the Coroner will complete and sign the MCOD. If the
  • Coroner determines that the death does not have to be investigated, the Clinician will complete and sign the MCOD.
  • Is provided with answers to all questions and to requests for additional information about MAID or any of the above items.

The Clinician has an obligation to take reasonable steps to ensure that the patient has understood the information provided regarding their health status and MAID. If the patient has difficulty communicating, the Clinician must take necessary measures to provide a reliable means by which the patient may understand the information provided and communicate their decision.1, 2, 3

The following resource may be helpful to Clinicians when assessing voluntariness and informed decision making with respect to patients from vulnerable populations:
Grievous and Irremediable Medical Condition

A patient’s condition is grievous and irremediable if ALL of the following criteria are met: 1, 2, 3, 4

  • Serious and incurable illness, disease, or disability;
  • Advanced state of irreversible decline in capability;
  • Enduring physical or psychological suffering as a result of the illness, disease, or disability that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and
  • Natural death has become reasonably foreseeable (precise proximity to death is not required).

As stated in Justice Canada’s Legislative Background: Medical Assistance in Dying, “ the medical condition that is causing the intolerable suffering does not need to be the cause of the reasonably foreseeable death”. The patient’s natural death is foreseeable, if it is expected to transpire within “a period of time that is not too remote”.

The following resources may be helpful to Clinicians when assessing the patient’s condition:
Conducting Eligibility Assessments for MAID

Two independent* Clinicians (e.g., two medical practitioners, two NPs, or one medical practitioner and one NP) must separately conduct an assessment to ensure that the patient meets ALL the criteria required to be eligible for MAID and provide their opinion in writing to confirm the patient’s eligibility.1, 2, 3, 4

Eligibility needs to be assessed on a case-by-case basis to reflect the uniqueness of each patient’s circumstances. It is encouraged that Clinicians consult their colleagues to obtain additional information that may support assessment of patient eligibility for MAID.

Example 1: Clinician suspects that a patient’s mental health condition may be impacting the ability to make decisions with respect to their health and initiates a psychiatric consult to help assess capacity.

Example 2: Clinician consults a neurologist to confirm the finding that a patient’s natural death has become reasonably foreseeable due to their neurological condition.

* To meet the legal conditions for independence, each Clinician must ensure that they:1

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

Inclusion of Family Members, Caregivers, and Friends

There is no formal notification process to inform family/caregivers of a patient’s decision to pursue MAID. A patient should be encouraged to speak with family members and/or caregivers about the choice to pursue MAID. The patient is not obligated to inform their family/caregivers of their decision to pursue MAID. With the patient’s consent, discussions between the Clinician and family/ caregivers should occur either before or after a formal request for MAID has been made.

Care Team

The provision of MAID will require a collaborative care team, including allied health care providers, support care personnel, and/or administrators, depending on the clinical practice setting. Early in the process, Clinicians are encouraged to identify and engage the appropriate individuals to discuss the roles and responsibilities of each team member in the provision of MAID (e.g., pharmacist). It is encouraged that the care team review and debrief after the provision of MAID has been completed for a patient. The process can be an overwhelming and emotional experience for the Clinician and care team. The use of wellness resources and supports is encouraged to promote self-care.

CALL:
Confidential Toll-free Line: 1-800-851-6606

On December 13, 2016, the Government engaged the Council of Canadian Academies (CCA) to conduct independent reviews related to specific types of requests for medical assistance in dying – requests by mature minors, advance requests, and requests where a mental disorder is the sole underlying medical condition. These issues were the subject of debate when Bill C-14, the Government’s legislation on medical assistance in dying, was being considered by Parliament. The Act required the Ministers of Health and Justice to initiate independent reviews on the three issues and table reports in Parliament within 2 years of initiation. The final reports on these reviews have been tabled in Parliament and are now available to the public on the CCA website.

Clinician Develops Care Plan for the Provision of MAID

The Clinician develops a care plan for the provision of MAID through discussions with the patient, family/caregivers (with consent) and other members of the care team.

Care Plan Considerations:

  • Determine the method of providing MAID that is most appropriate for the patient given their wishes, health status, and available supports;
  • If the patient plans to self-administer the medication for MAID at home, Clinicians must help the patient and family/caregivers assess whether this is a manageable option;
  • Ensure that the care team is briefed of process that will be undertaken to provide MAID for the patient;
  • Inform pharmacist that the prescription will be used for the purpose of MAID; and
  • Ensure appropriate arrangements are made with respect to drug protocols (e.g., IVs are set up correctly; plan for what to do if initial drug fails; care team is aware of their roles, etc.).
Organ and Tissue Donations

Trillium Gift of Life Network (TGLN) Patients may be eligible to donate tissue and organs after MAID. Offering the opportunity for donation is part of the provision of high-quality end of life care. Through collaboration with the Clinician and TGLN, this conversation should take place early enough to facilitate patients incorporating the decision to donate into their planning for MAID.

Designated facilities and sites are required to notify TGLN of all patients whose death is imminent by reason of injury or disease as per section 8.1 of the TGLN Act.7

CALL:
Toll free (1-877-363-8456)
GTA (416-363-4438)

Preparing for Self-Administration
  • Family members and/or other caregivers are legally able to help the patient self-administer the lethal medication for MAID, provided that the patient explicitly requests the individual’s help
  • Ensure that the patient or responsible family member/caregiver has the ability to store the medication in a safe and secure manner so that it cannot be accessed by others
  • Develop plan for the return of unused medication, in the event that patient chooses not to proceed with MAID
  • Ensure that the patient and family/caregivers are educated and prepared for what to expect once the patient has ingested the lethal medication and their death is imminent
  • Ensure that the family/caregivers are prepared for what to expect and what to do when the patient has died (i.e., instructions on notifying Clinician to attend the location, reporting the death to the Office of the Chief Coroner, etc.)
  • Clinicians are encouraged to be present to support family/caregivers upon the patient’s death (e.g., notification of the Office of the Chief Coroner)
Informing the Pharmacist

The Clinician who prescribes or obtains a substance for the provision of MAID must inform the pharmacist that the substance is intended for that purpose, before any pharmacist dispenses the substance. It is encouraged that pharmacists are engaged as early as possible, once Clinician is aware that the patient is eligible for MAID.4 Collaboration at an early stage will ensure that eligible patients are able to access required medications and supplies in a timely manner.

Discussions with the pharmacist should include: 4

  • The drug protocol selected;
  • The scheduled time and location for the administration of MAID;
  • The time required to prepare (or obtain) the pharmaceutical agent(s);
  • Whether there is a specific date after which the prescription should not be dispensed;
  • Procedures for returning unused drugs to the pharmacy for safe disposal; and
  • Any other relevant information required by the pharmacist.

The dispensing pharmacist is required to report to Health Canada via the Canadian MAID Data Collection Portal within 30 days of dispensing the drugs.

Drug Protocols

Clinicians must exercise their clinical judgment in determining the appropriate drug protocol to follow for the provision of MAID.
Irrespective of the chosen drug protocol for MAID, Clinicians should ensure that the patient is comfortable and that pain and anxiety are controlled. The cost of drugs, including the backup kit, for all eligible patients are covered regardless of the mode of administration.

The Reflection Period

The reflection period is intended to provide both the patient and the Clinician an opportunity to consider the request for MAID. This allows the patient sufficient time to reach an informed and voluntary decision to end their life, while appreciating the consequences of the decision.

There must be at least 10 clear days between the day on which the request was signed by or on behalf of the patient, and the day on which MAID is administered or the prescription for MAID is written.

EXCEPTIONS: If both Clinicians (Clinician providing MAID and Clinician conducting second eligibility assessment) are of the opinion that the patient’s death, or the loss of their capacity to provide informed consent is imminent — a shorter period is allowed, as deemed appropriate by the first Clinician for the circumstances.1, 2, 3 It is contrary to federal law to shorten the 10-day reflection period for any reason other than the circumstances outlined here.

Provision of MAID

Notification of the Coroner

Under the current law, all Clinician-administered and self administered MAID deaths must be reported to the Office of the Chief Coroner. Once a death is reported, the Office of the Chief Coroner will speak with Clinicians and family members. Clinicians must be prepared to provide the required information to make the process as efficient, effective, and appropriate as possible.

Office of the Chief Coroner:
1-855-299-4100
NOTE: Upon the patient’s death, it is recommended that the Clinician be present to support family/caregivers (e.g., notification of the Coroner’s Office), even in cases of self-administration

It is recommended that Clinicians who provide MAID have complete medical records on-hand and accessible, in order to provide any information that the Coroner considers necessary to ensure complete reporting and to determine whether further steps are required to investigate the death. The Clinician will complete and sign the death certificate in all cases except for occasions when the coroner completes additional investigation.

Documentation Checklist

Please see Documentation Checklist for a list of documentation that should be included in the patient’s medical record. These records should be on-hand and accessible to support an efficient and effective investigation by the Office of the Chief Coroner.

Supporting Materials

[i] CPSO Policy Statement #4-16: Medical Assistance in Dying
[ii] CPSO Fact Sheet: Ensuring Access to Care – Effective Referral
[iii] CNO Guidance on Nurses’ Roles in Medical Assistance in Dying
[iv] OCP Code of Ethics
[v] Clinician Aid A – Patient Request for Medical Assistance in Dying
[vi] Clinician Aid B – (Primary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying Aid
[vii] Clinician Aid C – (Secondary) “Medical Practitioner” or “Nurse Practitioner” Medical Assistance in Dying Aid
[viii] NICE Capacity and Consent Tool
[ix] Aid to Capacity Evaluation (ACE)
[x] Assessment of Capacity to Consent to Treatment (ACCT): Challenges, the “ACCT” Approach, Future Directions
[xi] College of Physicians and Surgeons of Ontario Policy Statement #3-15: Consent to Treatment
[xii] CNO Practice Guideline: Consent
[xiii] Assessing Vulnerability in a System for Physician-Assisted Death in Canada
[xiv] Justice Canada’s Legislative Background: Medical Assistance in Dying (Bill C-14, as Assented to on June 17, 2016)
[xv] The Gold Standards Framework (GSF) Prognostic Indicator Guidance
[xvi] Supportive and Palliative Care Indicators Tool (SPICTTM)
[xvii] Mississauga Halton Regional Hospice Palliative Care Early Identification and Prognostic Indicator Guide
[xviii] Murray SA, Kendall M, Boyd K, Sheikh A. Illness Trajectories and Palliative Care. BMJ.
2005;330(7498):1007-1011

[xix] Department of Justice Canada: Medical Assistance in Dying Glossary
[xx] Ontario Medical Association: Physician Health Program

[xxi] CPSO Policy Statement #6-16: Planning for and Providing Quality End-of-Life Care
[xxii] TGLN: Public Reporting (List of Designated Facilities and Sites)
[xxiii] CPSO Drug Protocols – Member Login

Additional supporting materials and resources that may be useful for Clinicians:
[xxiv] Canadian Nurses Protective Society: Medical Assistance in Dying: What Every Nurse Should Know
[xxv] College of Nurses of Ontario Medical Assistance in Dying – FAQS
[xxvi] CPSO Policy Statement #4-16: Medical Assistance in Dying
[xxvii] FAQ about the Vulnerable Persons Standard
[xxviii] OCFP: Medically-Assisted Dying
[xxix] OCP: Medical Assistance in Dying: Guidance to Pharmacists and Pharmacy Technicians
[xxx] TGLN: Routine Notification for Designated Hospitals FAQ
[xxxi] Vulnerable Persons Standard
[xxxii] MAID Training Program developed by the Canadian Medical Association Online Modules

Additional resources regarding community deaths and palliative care:
[xxxiii] Cancer Care Ontario’s Palliative Care Toolbox: The CCOs Palliative Care Toolbox includes links to best-practice tools from around the world to support primary care providers in the delivery of palliative care.
[xxxiv] Symptom Response Kits: System response kits are developed for patients receiving palliative care at home who may require unanticipated symptom management or for those with rapidly escalating symptoms
[xxxv] Hospice Palliative Care Ontario (HPCO): HPCO’s website includes a number of links toeducation resources from clinicians, patients, and families/caregivers

*These supporting materials are hosted by external organizations and as such, the accuracy and accessibility of their links are not guaranteed. CEP will make every effort to keep these links up to date.

References New

  • [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 and Surgeons of Ontario Policy Statement #4-16: Medical Assistance in Dying. 2016. [cited 2016 June]. Available from: https://www.cpso.
    on.ca/Physicians/Policies-Guidance/Policies/Medical-Assistance-in-Dying#Conscientious-Objection

  • [3]

    College of Nurses of Ontario: Guidance on Nurses’ Roles in Medical Assistance in Dying. 2016. [cited 2016 June 27]. Available from: http://www.cno.org/globalassets/
    docs/prac/41056-guidance-on-nurses-roles-in-maid.pdf

  • [4]

    Ontario College of Pharmacists: Medical Assistance in Dying – Guidance to Pharmacists and Pharmacy Technicians. 2016. [cited 2016 July 5]. 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. [cited 2016 September 30]. 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

  • [8]

    Bill 84: An Act to amend various Acts with respect to medical assistance in dying (ON) [Internet]. c2017 [cited 2017 Nov 2]. Available from: http://www.ontla.on.ca/
    bills/bills-files/41_Parliament/Session2/b084ra_e.pdf

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