Medical assistance in dying: Implementing the framework
This page builds on questions from provinces, territories and practitioners involved in medical assistance in dying. It explains how healthcare providers can consistently apply Canada's medical assistance in dying (MAID) framework to assessments and delivery of MAID. This information will be updated periodically.
On this page
- Points of reference
- Assessing reasonably foreseeable natural death (RFND)
- Procedural safeguards for individuals: RFND
- Procedural safeguards for individuals: Non-RFND
- Federal data collection and reporting
Points of reference
The Criminal Code
The Criminal Code includes the legal framework for medical assistance in dying (MAID), as originally set in former Bill C-14, and recently in Bill C-7 (sections 241.1 to 241.31). The Criminal Code will always prevail in the case of any discrepancy or inconsistency between additional information on this page and the MAID legislation.
Provinces and territories may create further policies and standards with respect to MAID. However, they cannot permit actions that the Criminal Code prohibits.
Contact your health ministry and professional regulatory body:
- for information about professional standards
- if you have any questions about how to apply the legislation
Federal Regulations for the Monitoring of MAID
The Regulations Amending the Regulations for the Monitoring of Medical Assistance in Dying require physicians, nurse practitioners, preliminary assessors, pharmacists and pharmacy technicians to provide information related to requests for, and the provision of, medical assistance in dying (MAID).
Health Canada has provided a guidance document to support these health care professionals in fulfilling their responsibilities under the Regulations.
Advanced state of irreversible decline in capability
One of the criteria that determines if someone has a grievous and irremediable medical condition is 'an advanced state of irreversible decline in capability'. With this, they might qualify for MAID. The meaning of 'advanced state of irreversible decline in capability' has not changed in the new law.
The loss of capability can be:
- sudden or gradual
- ongoing or stabilized
Someone can be in an advanced state of irreversible decline in capability in general terms, while still having moments of slight improvement.
The medical community may develop guidance and standards of practice to address further details.
Assessing reasonably foreseeable natural death (RFND)
Reasonably foreseeable natural death (RFND) is no longer an eligibility criterion. Practitioners instead must use it to determine which set of safeguards to apply to someone requesting MAID.
The meaning of RFND hasn't changed in the new law. It requires a temporal, but flexible, connection between the person's overall medical circumstances and their anticipated death.
People may decline toward death at different rates that aren't always predictable. As such, 'reasonably foreseeable natural death' isn't defined by a specific prognosis. However, it does require the person to be approaching the end of their life in the near term.
When you assess RFND:
- consider each individual's unique medical circumstances
- do so on a case-by-case basis, in relation to the specific person seeking MAID
Disagreement between MAID assessors
The legislation does not expressly state that the two assessors must agree whether a patient's death is reasonably foreseeable. However, the assessors should discuss their respective views on this question. They can then appropriately determine which set of safeguards to apply in a given case.
The medical community may develop guidance for practitioners in this situation regarding how to reach an agreement, such as:
- seeking an opinion from a third assessor
- consulting with another practitioner familiar with the patient's condition
Procedural safeguards for individuals: RFND
Wavier of final consent
A waiver of final consent is only available to persons whose natural death is reasonably foreseeable and who have:
- been assessed and found eligible for MAID
- scheduled a date for their MAID procedure
- been advised they are at risk of losing the capacity to provide final consent prior to their scheduled date for MAID
An individual could lose capacity from:
- using medications
- a complication of their medical condition
- the progression of their medical condition
An individual is not required to reduce or eliminate medications for the purposes of retaining or regaining capacity.
In the case of a loss of capacity, medical regulators would advise that you always follow good medical practice including the patient's expressed wishes. For example:
- addressing infections
Scheduling a date for the MAID procedure
The waiver of final consent arrangement intends to prevent assessed and approved people from choosing a date to receive MAID sooner than they need to. They may be afraid of losing capacity to consent and no longer be able to receive MAID.
This option should not be used as a form of an advance request. Advance requests for MAID aren't permitted under the law. It's one of the topics being considered by a parliamentary review.
The waiver of final consent arrangement must include consent from the patient that they agree to receive MAID on or before the day specified in the arrangement if they lose their capacity to consent to receive MAID prior to that day.
The patient is the only one who can determine the date of provision, assuming the date is acceptable to the provider.
The legislation does not:
- pronounce on specifying alternative dates
- impose a time limit on the specified date to receive MAID
A patient and their MAID provider should enter into a new arrangement for the waiver of final consent if the patient wishes to change their original specified date.
The medical community may develop guidance on timelines for specifying dates under a waiver of final consent arrangement.
Moving the specified date ahead in the case of lost capacity
The arrangement for a waiver of final consent could include consent from the patient to receive MAID sooner than the specified date if they've lost capacity before then. The patient should set out the parameters describing:
- what should happen
- how to determine the date of provision
Many regulatory bodies would recommend that, to the degree possible, the practitioner and patient:
- discuss various potential scenarios, including those that might result in an acute loss of capacity
- document the patient's wishes in the written arrangement
- include the patient's family and loved ones or inform them of these discussions to avoid potential conflicts regarding the date of provision
You do not need a new arrangement if a patient consents to receive MAID earlier than their specified date due to loss of capacity.
Practitioners named in the written arrangement
MAID legislation requires the arrangement to include the following details:
- the name of the practitioner to administer MAID
- the date that MAID is to be administered
- explicit patient consent for the administration of MAID:
- on the date
- prior to that date, upon loss of capacity (only if the patient wishes to include this in the arrangement)
The legislation doesn't prohibit the use of alternative practitioners to be named in the arrangement (for example, in case the original practitioner is suddenly unavailable). However, in all cases, the practitioner who provides MAID must:
- have personally assessed the patient and found them eligible while the patient still retained capacity to provide informed consent
- personally ensure that all the safeguards have been satisfied
- be named in the arrangement
- agree to enter into the arrangement with the patient
Setting conditions instead of a date
The legislation requires that the arrangement specifies a date. However, the arrangement can describe specific conditions or circumstances where the patient could receive MAID on an earlier date, if they:
- consented in the written agreement
- have lost capacity before their originally specified date
Refusing to provide MAID
The legislation and the provisions on the waiver of final consent do not impose any legal duty on the practitioner to provide MAID. Even if earlier they agreed to do so, they do not have to provide MAID.
Declining to fulfill the terms of a waiver of final consent could result in a situation where the patient, who has subsequently lost capacity to consent:
- cannot enter into a new arrangement with an alternate provider
- cannot receive MAID unless they regain capacity to consent
Practitioners should advise the patient as soon as possible if they feel they can't fulfill the terms of the arrangement, for any reason.
Signatures, witnesses and proxies
The legislation doesn't specify that the written arrangement for a waiver of final consent be signed and dated by the patient or practitioner. It also doesn't require witnesses to the written arrangement.
Provinces, territories and professional regulatory bodies may establish guidance for written arrangements for the waiver of final consent that could include:
- requirements for both the patient and the provider to sign the written agreement
- whether a proxy for the patient can sign on their behalf
Involving family/loved ones
Practitioners may wish to encourage the patient to share their intentions and involve their family or loved ones in discussions about receiving MAID. This way, family and friends will be aware of the patient's wishes and more likely to respect them.
A patient's family or loved ones may attempt to prevent a practitioner from administering MAID to the patient under the terms of a waiver of final consent arrangement. This would be a matter of health law, medical ethics or medical practice, which is a matter of provincial or territorial responsibility.
The demonstration of refusal through words, sounds or gestures
The written arrangement becomes permanently invalidated if 'a person demonstrates, by words, sounds or gestures, refusal to have the substance administered or resistance to its administration'.
Involuntary words, sounds or gestures made in response to contact do not constitute a demonstration of refusal or resistance.
Medical regulators would expect practitioners to:
- use their professional medical judgement to determine whether a person is demonstrating refusal
- document their basis for concluding that the patient did or did not demonstrate resistance and/or refusal
Procedural safeguards for individuals: Non-RFND
Expertise in the condition causing the individual's unbearable suffering
Expertise in the condition
One of the two practitioners assessing eligibility must have expertise in the medical condition that is causing a person's unbearable suffering. If neither of these practitioners have this expertise, another practitioner with the expertise must be consulted. The practitioner with expertise does not have to have a specialization or certification. They may obtain their expertise through, for example:
- special training and application
- previous experience with patients with a similar condition
It is possible that a family physician could be considered to have the necessary expertise if:
- the condition causing the patient's greatest suffering is within their scope of practice
- they have the knowledge, skill and judgment to treat that condition, including being aware of reasonable and available treatments that might relieve that suffering
When to consult a practitioner with expertise
Assessors may feel they have insufficient knowledge and experience in the condition causing the individual's greatest suffering for them to:
- complete their assessments
- meet the procedural safeguards for applicants whose death is not reasonably foreseeable
In this event, they must consult with a practitioner with expertise.
The consultation must be related to the aspect of suffering that is:
- most unbearable to the patient
- driving their request for MAID
Assessors may not need to consult a practitioner with expertise if:
- the condition causing the patient's unbearable suffering is within one of the assessors' scope of practice
- one of the assessors has the knowledge, skill and judgment to treat that condition, including being aware of reasonable and available treatments that may relieve that suffering
In this case, an assessor may have the necessary expertise.
Consulting with a practitioner with expertise
Only one assessor is required to consult with the practitioner with expertise. However, that assessor must share the information with the other assessor.
Practitioners with expertise should consider providing their information in writing. This way assessors can share the information as the practitioner with expertise originally expressed it.
The practitioner with expertise does not assess a patient's eligibility for MAID.
The condition causing suffering
The 'condition that is causing the person's suffering' is a broader concept than the person's 'medical condition'. In most cases, the condition causing the unbearable suffering will be the 'serious and incurable illness, disease or disability'. However, it can also be:
- their state of advanced decline in capability
- their generalized pain associated with their multiple morbidities
- a broader concept involving psychological, existential or psychosocial suffering that flows from their:
- state of decline or
- illness, disease or disability
The assessor needs to assess the greatest source of suffering to determine what expertise is required.
Purpose of the consultation with the practitioner with expertise
The expertise consult should provide information on the unbearable suffering that the patient is experiencing. Assessors need this information to complete a fully informed assessment of the patient.
The consultation may include advice on the:
- reasonable and available types of services and treatment options that might relieve the patient's unbearable suffering
- medical aspects of the patient's illness or disease, such its:
- status of the patient's state of decline based on their knowledge of the medical condition's trajectory
Prior consultation with another practitioner with expertise
The patient may have had a consultation with another practitioner with expertise prior to being assessed for MAID. To decide if this consultation qualifies as an "expertise consultation" as required under the law, the assessor should consider:
- how long ago the prior consultation took place
- whether the prior consultation adequately addresses the assessors' questions about the:
- nature of their unbearable suffering
- reasonable and available options for relieving that suffering
If a prior consultation is recent and comprehensive, the assessor may meet the safeguard by having a discussion with the practitioner that did the prior consultation and reviewing the practitioner's relevant written records.
The medical community may develop guidance on prior consultations in the context of its:
- completeness or current nature
- adequacy in the context of a request for MAID
Seeing the patient in person
The legislation does not expressly require that the practitioner with expertise in the condition causing the suffering personally meet with the patient.
The steps required in any given case will depend on:
- the practitioners involved in the case
- guidance and practice standards developed by the medical professional community, which could include:
- the type of information the assessors need
- whether the practitioner with expertise can adequately respond to the assessors without seeing the patient in person
For example, if the assessors only need information on local support services, the practitioner with expertise may not need to meet the patient. In some cases, they may only need to examine the patient's chart to respond to the assessor's questions.
The medical community may develop guidance advising on whether a virtual consultation with the patient is appropriate. This could address circumstances where distance and availability pose a barrier to the assessment process.
Providing information to the assessors
The legislation does not require the practitioner with expertise to provide the information in a specific manner.
If only one assessor is consulting a practitioner with expertise, that assessor must share the feedback with the other assessor. Written information would be the easiest and most accurate method for sharing. It also lets the assessor see the information as originally expressed by the practitioner with expertise.
Multiple consultations in the case of comorbidities
In the event of comorbidities, assessors must consult with a practitioner with expertise in the medical condition that is:
- most responsible for the patient's suffering
- the reason for the patient's request for MAID
Areas with limited specialized services
Some areas, such as rural and remote situations, may not have easy access to practitioners with expertise.
Some provinces and territories have established care coordination services to help:
- coordinate access to MAID services
- facilitate access to practitioners with the necessary expertise
- facilitate telehealth or virtual consultation services
Local experts in various conditions
Provinces and territories may wish to identify consulting experts for medical conditions that assessors find more challenging to assess. A list of experts may facilitate the process in cases where a person's unbearable suffering is primarily a function of the medical aspects of their condition.
Assessors should not assume that they need expertise in a particular illness or disease if the patient has that illness or disease. The particular nature of the person's unbearable suffering, not their illness or disease, is what must determine the necessary expertise.
'Expertise' does not necessarily imply a specialist. They may be a practitioner with extensive knowledge of the patient's history and the progression of their suffering, such as a family physician. In this case, they might not be on a list of local experts.
Inform the individual of all reasonable and available means to relieve their suffering
Informing the patient
The MAID assessor is responsible for:
- making the patient aware of available treatments and services that might relieve their suffering
- providing the patient with a description of the treatments and services and their potential impact
- giving the patient the opportunity to speak with relevant professionals who provide these treatments and services
The patient does not have to try the treatment or support services.
Timelines for referral to other treatments or services
The legislation does not specify a timeline within which a referral to other treatments or services must take place.
The medical community may develop guidance for situations where a person is interested in a referral to alternative treatment or service options, but where arranging access to these services is taking significant time.
90-day minimum assessment period
The 90-day minimum assessment period and the former 10-day reflection period
Changes to the law in March 2021 removed the 10-day reflection period from the legislation on MAID. This period started after a patient was told they were eligible for MAID, and gave them time to reflect on whether to proceed.
The 90-day minimum assessment period has a different purpose.
This period is applied to individuals whose natural death is not reasonably foreseeable. The law requires that at least 90 clear days must pass between the day on which the first assessment begins by a MAID assessor and the day MAID is provided.
It intends to ensure that the patient and assessors have enough time to explore relevant aspects of the patient's situation. It doesn't have to provide reflection time for the patient, although it could do this as well.
Beginning of the assessment period
The assessment period begins on the day that the first assessment of whether the patient meets the eligibility criteria begins. Only the MAID assessor can trigger the beginning of this period.
For example, the first day of the assessment period could be triggered by the assessor:
- reviewing the patient's file
- meeting with the patient
- engaging in any reflection or consideration of information that forms part of a specific assessment for MAID
The date of the start of the assessment period should be documented, such as in a patient's medical record.
The assessment period can begin before the assessor receives the official request form signed by the patient and doesn't depend on the completion of the patient's official request.
The 90-day period represents a minimum assessment period. It can be shortened in a specific circumstance where both assessors:
- agree the patient is at imminent risk of losing capacity to consent, and
- have completed their assessments, and
- agree the patient is eligible to receive MAID.
Federal data collection and reporting
Federal reporting requirements
The revised law authorizes the expansion of federal data collection and reporting on MAID. As a result, Health Canada has amended the 2018 MAID Regulations which came into effect on January 1, 2023. The Regulations Amending the Regulations for the Monitoring of MAID include new and enhanced reporting requirements for MAID for physicians, nurse practitioners, preliminary assessors, pharmacists and pharmacy technicians. Health Canada has created an updated guidance document to provide those who must report with additional information about the changes in reporting.
Provincial and territorial ministries of health, regulatory bodies and health authorities may introduce additional reporting obligations.
Contact your provincial or territorial ministries of health or regulatory bodies for more information.
Changes in reporting forms
Health Canada has worked with provincial and territorial governments to incorporate new data elements in jurisdiction-specific reporting forms used to collect information about MAID from physicians, nurse practitioners, preliminary assessors and pharmacy professionals, as required. For physicians, nurse practitioners, preliminary assessors and pharmacy professionals who report directly to Health Canada, the Government of Canada has revised its online reporting tool, the Canadian MAID Data Collection Portal, to collect the new required information.
Reporting on the dispensing of substances
The original legislation requires a pharmacist to report when they dispense a substance in connection with the provision of MAID. In jurisdictions where pharmacy technicians or their equivalent can also dispense these substances, these professionals are also required to report under the new legislation.
While the Regulations refer to a pharmacy technician dispensing a substance, this wording should be interpreted as a pharmacy technician collaborating with a pharmacist to dispense a substance. Specifically, it is understood that a pharmacy technician may verify the technical aspects of the prescription, but must always collaborate with a pharmacist who verifies the clinical/therapeutic aspects of the prescription.
The amended federal Regulations for the Monitoring of MAID came into effect on January 1, 2023. Health Canada has provided updated guidance on reporting by pharmacy technicians.
The National Association of Pharmacy Regulatory Authorities considers the dispensing pharmacist or pharmacy technician to be the one that verifies and signs off on the substances once they are prepared.
Where more than one substance is dispensed for the purposes of providing MAID to a person, only one report, submitted by either the pharmacist or the pharmacy technician, is required. It should also be noted that the legislation and the Regulations refer to dispensing "a substance" in connection with the provision of MAID, however, it is understood that more than one substance is often dispensed for the provision of MAID.
For the purposes of reporting, the dispensing date is considered as the day on which the substance was prepared, and not the day of delivery to, or pick up by, the physician, the nurse practitioner or the person.
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