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
Medical Assistance in Dying (MAID): Ontario
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
Bill 84, the Medical Assistance in Dying Statute Law Amendment Act, 2017 amended six existing Ontario statutes. Notably, Bill 84 included an amendment to the Coroners Act to ensure effective oversight of MAID, including:
- 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.
Nurse Practitioner: A registered nurse who is entitled to practise as a nurse practitioner 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.
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
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 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.
Resources outlining referral guidelines for medical practitioners:
- College of Physicians and Surgeons of Ontario (CPSO) Policy Statement #4-16 Medical Assistance in Dying
- CPSO Fact Sheet: Ensuring Access to Care – Effective Referral
Resources outlining referral requirements for nurse practitioners:
- College of Nurses’ of Ontario (CNO) Guidance on Nurses’ Roles in Medical Assistance in Dying
Resources outlining referral requirements for pharmacists:
- Ontario College of Pharmacists’ (OCP) Code of Ethics