Understanding Medical Assistance in Dying (MAiD)
By Alex Muir, Chair of Metro Vancouver Dying with Dignity Canada
and Connie Jorsvik, Senior Healthcare Navigator and Patient Advocate of Patient Pathways
Updated December 2023
Overview:
Medical Assistance in Dying (MAiD) is a legal choice for capable adults living in Canada (receiving health benefits) who are over 18 who want to end their lives when they are suffering grievously (severely or seriously), and their condition is irremediable (impossible to cure). The adult must be capable of making an informed decision regarding MAiD at the time they are assessed.
Under the recently amended legislation, there are two paths: natural death is reasonably foreseeable, and when natural death is not reasonably foreseeable.
In March of 2021, the legislation was amended so that the adult no longer has to be capable at the time MAiD is administered if their death is reasonably foreseeable. There is now also a path to MAiD if their death is not reasonably foreseeable.
MAiD is under federal legislation (with the exception of Quebec) but administered by each province or territory as it is under the healthcare umbrella.
The cost is covered by provincial health care (BC Medical Services Plan).
A request for MAiD is a patient-led conversation. If you want to discuss MAiD, you should be the one to bring it up. Your healthcare team (doctors and nurses) Your healthcare team is heavily discouraged from starting the conversation.
How to Request MAiD
1. Complete the BC Request for Medical Assistance in Dying (Form 1632)
If you or someone you are helping is considering MAiD, complete the form as soon as you feel you meet the medical criteria and then get assessed. If your request for MAiD has been approved, your approval doesn’t expire. You can “put it in your back pocket,” knowing that the option is open and can be acted on quickly should you decide to proceed.
Reach out to the MAiD Coordinators (see below). This can be initiated by an adult, a family member, or a friend. This is a self-referral process. Your doctor does not have to refer you, and they can choose to do a first assessment or not. However, your family doctor will be contacted for your medical history.
If your family doctor does not support your decision to proceed with MAiD, contact the MAiD Coordinators for your health authority for advice. See more about professional standards and conscientious objections (in section 6 of this blog.)
2. Speak to a MAiD Coordinator in your health authority
Island Health (VIHA)
Additional Resources:
Dying With Dignity Canada (free services)
Email: support@dyingwithdignity.ca Phone: 416-486-3998
Toll-free: 1-800-495-6156
Dying with Dignity can help with:
Understanding your rights to MAiD and ongoing advocacy initiatives
Advance care planning information and resources
Information services — list of resources on the website
Stories, updates, and events and webinars on end-of-life topics
Contact Connie Jorsvik at PatientPathways.ca (for-fee services):
One-on-one support from the beginning to the end of the MAiD process
Support with difficult conversations with friends and loved ones
Advance care planning
Estate and funeral resources
A Deeper Look at Medical Assistance in Dying
Over the last 40 years, there has been a slow and steady movement to decriminalize and normalize an adult’s choice in how they want their lives to end.
Canada has been — and continues to be — at the forefront regarding end-of-life choice. It has not come soon enough for people who are suffering from a severe, complex disease where life has become unbearable, but it is because of those people fighting for the right to choose the end of life for themselves and others that our laws have changed and continue to evolve.
In the past, medical assistance in dying was called euthanasia or assisted suicide. As these terms have negative connotations, we now use the term Medical Assistance in Dying (MAiD), or simply, “assisted dying.” MAiD is a planned death with the assistance of trained healthcare providers: physicians or nurse practitioners. Assessors and providers are most often doctors and nurse practitioners who are members of and have received training through the Canadian Association of MAiD Assessors and Providers (CAMAP): camapcanada.ca.
Stringent laws govern who is eligible for MAiD and the assessment and provision process.
MAiD can take place in two ways:
Clinician-assisted, which involves the administering of substances by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death.
Self-administered, which involves 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 death. (Bill C-14, s. 241.1) The use of oral medication is rare in Canada. Almost everyone chooses injection because it is quicker and more effective. The medication is bitter, and sometimes the adult will vomit. Therefore, a provider will insert an intravenous port and be immediately available if they must take over and give the medication.
Note: A medical practitioner must be in the room for either scenario.
1. Who Is Eligible for MAiD in Canada?
Any adult over 18 years of age who is capable of making decisions concerning their health and who is in a state of “grievous and irremediable medical condition” is eligible for MAiD in Canada; this means it has a serious illness, disease, or disability (as determined by the assessors). This person must be in an advanced state of decline that cannot be reversed (also as determined by the assessors); experience unbearable physical or mental suffering (as defined by the patient) from an illness, disease, disability, or state of decline that cannot be relieved under conditions that the person considers acceptable.
The patient must voluntarily request MAiD with no external pressure, and there must be informed consent and counselling. The individual must be informed of the alternative means to relieve suffering, including palliative care.
Mental illness as a sole underlying medical condition is currently excluded. Still, this exclusion will be lifted as of March 17, 2024, if the Parliamentary Subcommittee on MAID agrees that the appropriate safeguards are in place. Their recommendation on whether or not to proceed is expected by the end of January 2024.
2. Procedural Safeguards
The patient must make a written request: Form 1632 in BC
The form needs to be witnessed by one independent witness. (Under the original C-14 legislation, two witnesses were required)
A second physician or nurse practitioner must confirm eligibility using the same criteria
Must be independent of first assessor/provider (unchanged from C-14).
Waiting period:
No waiting period if death is reasonably foreseeable (was ten days under C-14)
Ninety-day wait period if death is not reasonably foreseeable (new under C-7).
The opportunity to withdraw the request at any time, including immediately before the MAiD provision (unchanged).
3. MAiD and Mental Capacity
To protect adults from coercion and pressure, the provision is that adults must be capable of making their own decision to access MAiD. Advance requests, allowing the adult to put their wishes in an advance directive, are front and center for future federal legislation.
A special note for family and loved ones: Over the years, I have received dozens of calls from families of an adult experiencing cognitive decline. Their loved one (usually a parent) has said things in their lives like, “I would never want to live like that!” The parent is now facing advancing cognitive decline, and their “that” is on the visible horizon.
Dementia is generally a life-ending diagnosis and, as such, can qualify under Track 1: Death is Reasonably Foreseeable (see below). However, adults must be capable at the time of assessment, so people with late-stage dementia may not qualify. It is essential to have assessments and MAiD provisions done before this happens.
This is a courageous conversation to have with your loved one. While you can contact the primary care practitioner and the MAiD Coordinators on their behalf, they must be the ones who understand and lead the conversation.
In my experience, it is best to have an honest, direct conversation that can start with something like, “Mom, remember when Uncle Bob was in (name of the long-term care facility), and you were so sad for him? You said to us, I never want to get like that. And then, last week, the doctor told us that you have early dementia. If you want Medical Assistance in Dying, we need to start to have those conversations now. I know this is a tough discussion, but are you up to discussing it with me?”
Each case will be different and needs to be evaluated by the assessor/provider.
Assessments must take place before losing the capability to make the decision. Therefore, start this process early and talk to the assessors/provider about a “Waiver of Final Consent.” By doing all this, the request can be “put in their back pocket,” and they can delay or not invoke the final provision at all – but it will be there and ready should they want to proceed.
— Connie
4. Two Streams for Assessment and Approval for MAiD
Track 1: Waiver of final consent if natural death is reasonably foreseeable
The waiver is only available to those approved for MAiD by two assessors assigned by the health authority MAiD Coordinators or located by the adult and whose natural death is reasonably foreseeable.
The adult must be at risk of losing the capacity to consent to MAiD when administered.
The applicant and MAiD provider sign the agreement (waiver) and set a date for the MAiD procedure.
Should the applicant lose capacity before the date arrives, the MAiD provider can proceed with the MAiD provision.
The MAiD provider can proceed with the procedure if there is no indication that the patient no longer wants MAiD (gestures, words, etc.).
Track 2: Safeguards if a natural death is not reasonably foreseeable
One of the medical doctors or nurse practitioners who provides an assessment must have expertise in the medical condition causing unbearable suffering.
If neither of these practitioners has this expertise, another practitioner with expertise in the medical condition causing the adult’s suffering must be consulted in the assessment process
The adult must be informed of available and appropriate means to relieve suffering, including counselling services, mental health and disability support services, community services, and palliative care, and the patient must be offered consultations with professionals who provide those services.
The adult and their practitioners must have discussed reasonable and available means to relieve suffering, and all agree that the adult has seriously considered those means.
The adult’s eligibility assessment must take a minimum of 90 days unless the assessments have been completed sooner and the adult is at immediate risk of losing the capacity to consent.
Immediately before MAiD is provided, the practitioner must allow the patient to withdraw the request and ensure that express consent to receive MAiD is given.
5. Practical Considerations for MAiD
When friends and family object:
The most commonly asked question is, “What if someone in my family objects to me having a MAiD death?”
It is the individual’s right to choose MAiD; no one can block an eligible adult from accessing it. With that said, difficult conversations can be helpful and even therapeutic. A suggestion for accessing MAiD is to write out what you are dealing with and the reasons that you believe MAiD is the best option for you. This will help you prepare for the conversation — and, if necessary, you can read out the letter or give it to loved ones to read. Give them time to absorb the news and the information (you might want to provide them with a copy of this chapter); you will have been thinking about this for some time, so allow them the time to do the same.
Having these difficult conversations is most often a gift for yourself and your loved ones and can help reduce complicated grief after your death.
When planning for MAiD, things to think about:
Is essential paperwork in order, especially the will? If the patient is very ill, search for a mobile notary public or estate lawyer who can come to you.
A funeral home must be selected and in place before MAiD takes place. Most funeral providers are MAiD-friendly. Plan ahead and give them the date and time of the MAiD.
Where do you or the adult having MAiD want the procedure to happen? Discuss this with your MAiD provider or the health authority MAiD team.
Think about the last days and hours and make the day your own
Would you want a pre-death celebration?
Who do you want to be nearby or in the room with you?
Would you like certain music, reading, or food? (You can have wine or champagne — it won’t interfere with the medication.)
6. MAiD Access Issues
Rural access
Gaps exist in access to assessors due to their limited numbers. Virtual visits have helped alleviate some of these issues, but access to the provision of MAiD remains an issue, especially in northern communities.
Conscientious objectors
If asked, doctors who are “conscientious objectors” are supposed to provide an effective referral to another assessor. If your primary care practitioner does not want to do one of your assessments for any reason (whether they are conscientious objectors or do not feel they have the experience), reach out to the MAiD Coordinator for your health authority, and assessors will be assigned.
Forced transfer issues: Faith-based institutions
Faith-based institutions (the largest being Providence Health in Vancouver and Burnaby) that belong to the Denominational Health Association (denominationalhealth.ca) are allowed to opt out of providing services, including MAiD and abortions, which conflict with their mission statements. They are required to allow MAiD requests and assessments to occur onsite but not the provision of MAiD. This results in a “forced transfer” to a non-objecting facility which will accommodate MAiD provision. The transfer can be physically and emotionally painful, may separate the patient from their community of care, and there may be delays in providing pain medications and MAiD.
You may have read about Minister Dix’s announcement on Nov 28th, 2023 that the new St. Paul’s hospital (that will not open until 2026) will offer access to MAiD by providing a corridor to a facility next door operated by Vancouver Coastal Health. While this is a good first step by eliminating gruelling ambulance transfers by someone near end-of-life, it nevertheless still removes the patient from their community of care and continues to stigmatize MAiD. Also, it doesn’t address the forced transfers happening at all other faith-based hospitals, hospices and long-term care facilities in BC.
Ultimately, the B.C. government needs to address the Master Agreement with the Denominational Health Association to end religious exemptions in publicly funded faith-based facilities. If you agree, you can write to your MLA by joining one of the letter-writing campaigns launched by Dying With Dignity Canada or BC Humanists:
Read more about Dying with Dignity’s campaign on Institutional Religious Obstructions
BC Humanist Association: email your MLA for secular healthcare
7. MAiD and Palliative Care
MAiD and palliative care can co-exist within provincial and territorial healthcare systems across Canada. It provides better end-of-life care experiences for patients, families, and healthcare practitioners.
See “Palliative Care and MAiD: Co-existing in the New Environment.”
8. Assessors and Providers
Only physicians and nurse practitioners can determine who is eligible and provide MAiD.
Canadian Association of MAiD Assessors and Providers (CAMAP)
The Canadian Association of MAiD Assessors and Providers (CAMAP) was established in October 2016. It is a national nonprofit association comprised of clinicians, lawyers, pharmacists, social workers, care coordinators, and MAiD policy experts. CAMAP has partnered locally, provincially, and nationally with various organizations and MAiD stakeholders. It hosts three active online communities of practice, has produced 12 guidance documents, and has hosted ongoing training workshops, webinars, and educational symposia for MAiD clinicians. They are currently developing the Canadian MAiD Curriculum Project: a fully accredited, recognized, bilingual, seven-module MAiD education curriculum for clinicians entering the field has been completed.
Visit camapcanada.ca for more information.
Role of Primary Care Practitioners
According to the College of Physicians and Surgeons of BC’s Practice Standards, patients have the right to make decisions about their own bodies, and they should have access to unbiased, accurate information about their medical conditions and treatments. Physicians are obligated to provide non-discriminatory information and services and not abandon their patients. Physicians are expected to provide enough information to their patients so they can make their own informed choices.
With that said physicians have the right to be conscientious objectors to MAiD. Their care must remain continuous and non-discriminatory and treat their patients with dignity and respect.
If the physician objects to MAiD, they must assist and not abandon their patient. The doctor must pursue an effective transfer (including the use of a transfer form) if they receive a written request for MAiD; if it’s a verbal request, they must, at a minimum, provide information to the patient about MAiD and suggest they find another doctor who supports the process.
If, for any reason, your doctor does not support your choice in requesting MAiD, rather than trying to convince your doctor to provide an effective referral, it is likely more accessible and quicker simply to bypass your doctor by reaching out to the MAiD Coordination team in the local health authority. They will put you in touch with local MAiD assessors.
Excerpted from College of Physicians and Surgeons of BC Practice.
Patient] RIGHTS AND AUTONOMY
Patients have the right to decide about their bodily integrity (autonomy) and access to unbiased and accurate information about relevant medical conditions and their treatment. Registrants are obligated to provide their patients with health information and health services in a non-discriminatory fashion and not to abandon their patients. The College expects registrants to provide their patients with enough information and assistance to allow them to make informed choices for themselves. This includes consulting with other experts on relevant medical facts and when needed, competency assessments.
Conscientious objection registrants have the right to decide whether or not to perform medical assistance in dying. They may make a personal choice not to assess patients for and/or perform MAiD based on their values and beliefs. Nothing in the Criminal Code compels a person to provide MAiD. While a registrant is not required to make a formal referral on the patient's behalf, they have a duty of care that must be continuous and non-discriminatory. Registrants should not discuss their personal beliefs in detail with the patient and should not pressure patients to disclose or justify their beliefs. In all cases, registrants must practice within the confines of the legal system and always treat the patient with dignity and respect, according to the Canadian Medical Association Code of Ethics and Professionalism. www.justice.gc.ca/eng/csj-sjc/pl/ad-am/c7/p4.html
PRACTICE STANDARD Medical Assistance in Dying
May 10, 2022 (Version 7.2). Transfer of care Registrants who object to MAiD based on their values and beliefs are required to provide an effective transfer of care for their patients by advising patients that other practitioners may be available to see them, suggesting the patient visit an alternate physician or service, and if authorized by the patient, transferring the medical records as required. Where needed, registrants must assist the patient and not abandon the patient. Any registrant receiving a written request for MAiD who transfers the patient's care to another provider or care coordinator for any reason must complete the provincial form to report details about this transfer of care. Reporting is accomplished by completing and faxing or emailing the Transfer of Request (HLTH 1642) form to the Ministry of Health at 778-698-4678 or hlth.maidoversight@gov.bc.ca.
Nurse Practitioner assessors and providers have the following roles in MAiD:
Determining the eligibility of the person requesting MAiD based on the eligibility criteria in the Criminal Code.
Providing MAiD by prescribing, administering or providing the medication to a person, at their request, that causes their death.
Providing medication to a person, at their request, so that they may self-administer it and cause their death.
Aiding another physician or NP in the provision of MAiD.
Read more: BC College of Nurses and Midwives.
College of Pharmacists of BC
The College of Pharmacist’s bylaws around MAiD are at HPA Bylaws Schedule F.
