Medical assistance in dying and end‑of‑life decisions support for medical professionals

Overview

Medical assistance in dying (MAID) became legal in Canada in June 2016, with the passage of Bill C‑14, which amended the Criminal Code and other federal acts with respect to MAID.

Federal legislation sets out eligibility criteria for those who wish to request MAID, as well as the safeguards that a physician or nurse practitioner must follow to legally provide MAID.

On March 17, 2021, the federal government passed Bill C‑7: An Act to Amend the Criminal Code (Medical Assistance in Dying). Among other changes, Bill C‑7:

• expanded eligibility criteria for MAID to include individuals whose natural death is not reasonably foreseeable
• established a separate set of safeguards for individuals whose natural death is not reasonably foreseeable
• made amendments to the safeguards for individuals whose natural death is reasonably foreseeable
• expanded data collection through the federal monitoring regime

This expansion of eligibility included a temporary exclusion for individuals whose sole underlying condition is a mental disorder, which is still in effect. Please see Patient Eligibility

Any request for MAID may trigger reporting requirements for health care providers. Please see the Federal Regulations and Ontario's Hybrid Approach to the Reporting Requirements section below for more information.

Patient eligibility

Federal legislation creates a framework for MAID across Canada, including eligibility criteria. To be eligible for MAID, a patient must:

• be eligible for publicly funded health care services in Canada (or in the applicable waiting period)
• be 18 years of age or older
• be capable of making health care decisions
• have a grievous and irremediable medical condition, which means:
  • the patient has a serious and incurable illness, disease, disability
  • the patient is in an advanced state of irreversible decline in capabilities
  • the patient is enduring physical or psychological suffering, caused by the medical condition or a state of decline that is intolerable to the person and cannot be relieved under conditions that they consider acceptable
• be making a voluntary request
• provide informed consent to MAID

On February 29, 2024, the federal government passed Bill-C62 to officially delay the expansion of the eligibly criteria to include those whose sole underlying condition is a mental disorder, and who otherwise meet all eligibility criteria, to March 17, 2027.

Informed consent to MAID

For a patient whose natural death is reasonably foreseeable, the patient provides consent after having been informed of all means that are available to relieve their suffering, including palliative care.

For a patient whose natural death is not reasonably foreseeable, the patient provides consent:

• after having been informed of other means available to them, including counselling, mental health supports, disability supports, community services and palliative care
• after having been offered consultation with relevant professionals, as available and applicable
• after having discussed these means with the medical or nurse practitioner and given serious consideration to these means

Requests, assessments and access

A person should talk to a physician or nurse practitioner about options for care, which may include:

• MAID
• palliative care
• mental health supports
• other end-of-life care options

To make a formal request for MAID, the person, if able, must make a verbal or written request.

A person’s initial request (verbal or written) may take any form including Clinician Aid A, a text message or an e-mail. It must be more than an inquiry or a request for information about MAID.

To make a formal request in writing to receive MAID, federal legislation requires that an independent witness sign to confirm the signing and dating of the request. The witness must be at least 18 years of age and be able to understand the nature of the request for MAID. The witness must not:

• know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death
• be an owner or operator of any health care facility at which the person making the request is being treated or any facility in which that person resides
• be an unpaid caregiver to the person requesting MAID

A paid personal support or health care worker can be an independent witness, provided they are not the MAID provider or assessor of the person making the request.

Two independent physicians or nurse practitioners must confirm that a person meets the eligibility requirements as set out by Federal legislation.  If natural death is not reasonably foreseeable, one of the two providers confirming eligibility must have or consult expertise in the condition that is causing the person’s suffering and share the results of the consultation with the other assessing provider.

Under federal legislation, providers will be considered independent if they:

• are not a mentor to the other providers or responsible for supervising their work
• do not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death, other than standard compensation for their services relating to the request
• do not know or believe that they are connected to the other providers or to the person making the request in any other way that would affect their objectivity

The person must understand that they can withdraw a request for MAID at any time in the process.

If a person is found not to meet the eligibility requirements by their physician or nurse practitioner, the person can seek a second medical opinion.

Substitute decision-makers

Family members or friends cannot act as substitute decision-makers for MAID and have no legal authority to consent or override consent to or authorize MAID on behalf of a person.

Assessment period when death is not reasonably foreseeable

If a person’s natural death is not reasonably foreseeable:

• a minimum period of 90 days is required for assessment of the request
• in some cases, if both evaluating providers agree that the person’s loss of capacity is imminent, the minimum 90-day assessment period could be shortened, but only if the eligibility assessments can be completed in a shorter amount of time and the assessors are both of the opinion that the person’s loss of capacity is imminent

Accessing MAID: how to contact the care coordination service

Ontario has established a care coordination service to help the public and providers access information and supports for MAID and other end-of-life options. Through the care coordination service, individuals and their caregivers can receive information about:

• end-of-life options in Ontario, including hospice care
• other palliative care options in their communities
• MAID

Individuals and caregivers can also call the care coordination service to request to be connected to a physician or nurse practitioner who can provide MAID services, such as eligibility assessments.

This service also supports access to MAID by helping providers connect with either a:

• physician or nurse practitioner who can provide a second assessment to determine if a person meets all the eligibility criteria as set out in the Criminal Code of Canada
• community pharmacist or pharmacy technician who will dispense the drugs needed for MAID
• physician or nurse practitioner who will prescribe or administer the drugs required for MAID

Physicians, nurse practitioners, pharmacists, or pharmacy technicians who are unable or unwilling to provide MAID services can also contact the care coordination service in order to make an effective referral. Please see the Conscientious Objection and Obligations to Patients section below for more information.

Administering MAID

The federal legislation allows either:

• a physician or nurse practitioner to administer a substance directly to the person, such as through a drug injection
• a physician or nurse practitioner to prescribe or provide a substance to the person to self-administer, such as by orally ingesting drugs

An eligible person can request either option. For those who are covered by Ontario’s Health Insurance Plan (OHIP), the drugs and services required for MAID are normally available at no cost to the person.

In cases of self-administration, providers should ensure patients are aware that they can request a provider be present during the time of self-administration and make clear the risks if no provider is present.

Physicians and nurse practitioners registered in Ontario can provide MAID, either as the primary provider or as the secondary/consulting provider (who provides a written opinion confirming the person satisfies all the eligibility requirements for MAID).

Pharmacists or pharmacy technicians will dispense the drugs used to provide MAID.

Other health care professionals (such as nurses and social workers) can support a physician or nurse practitioner providing MAID. They can also provide information to a person on how MAID is permitted in Canada. Federal legislation also allows an individual, such as a family member, to help a person self-administer the drugs, provided that the person explicitly requests the individual's help.

The patient must confirm consent immediately before MAID drugs are administered by the provider, or before a self-administered prescription is written and provided to the person. There are some instances where this requirement for final consent can be waived if certain criteria are met. Please see the Waiving final consent section below for more information.

In addition to complying with federal and provincial MAID legislation in providing (or assisting in the provision of) MAID, health providers in Ontario must comply with any additional professional obligations required by their health regulatory colleges.

Waiving final consent

The requirement for providing final consent immediately before MAID is administered can be waived in certain circumstances. This may occur when a person’s natural death is reasonably foreseeable, and all the following criteria are met:

• the person was assessed as eligible for MAID and satisfied all the relevant safeguards
• the person was informed that they are at risk of losing decision-making capacity before the scheduled date to receive MAID
• the provider agrees to provide MAID on the scheduled date if the person has lost capacity (or earlier, after loss of capacity, if agreed)
• the person gives consent in writing to the provider to receive MAID on the scheduled date if they are no longer able to consent on that day

If, on the day of the MAID procedure, the person has capacity to consent to MAID, the provider must ensure that:

• the person gives express consent to receive MAID
• consent given in advance is invalidated if the person demonstrates, by words, sounds or gestures, refusal or resistance to the administration of MAID at the time of the procedure

Federal legislation also allows eligible individuals who choose to pursue MAID through self-administration to waive final consent.

This type of waiver of final consent would allow for a physician or nurse practitioner to follow through with providing MAID to the person should self-administration result in complications.

Dispensing drugs

Eligible individuals will not have to cover the cost of drugs used to provide MAID. In the hospital setting, drugs to administer MAID would be dispensed by the inpatient pharmacy and covered by the hospital. For the administration of MAID outside the hospital, such as a person self-administering the drugs in their home, drugs would be dispensed through community pharmacies at no charge to the person.

Under federal legislation, providers must inform the pharmacist or pharmacy technician that the prescription is intended for MAID before a pharmacist or pharmacy technician dispenses the prescription. Providers should make arrangements with pharmacies as early as possible to avoid delays in processing a prescription for MAID.

As with any unused medication, MAID drugs should be disposed of according to existing protocols and programs that assist people in disposing of unused medications. Many pharmacies are part of the Return Program where they accept and safely dispose of unused medications.

Providers can obtain information on MAID prescribing protocols from their respective regulatory colleges.

Accommodations

The federal legislation requires that, if a person has difficulty communicating, physicians and nurse practitioners take all necessary measures to provide a reliable means by which the person can understand the information provided to them and communicate their decision with respect to MAID.

Where MAID can take place

A person can request access to MAID from their providers whether they are in:

• hospital
• long-term care home
• hospice or palliative care facility
• in their own homes

Institutions that do not allow the provision of MAID, or that have limits on how MAID may be provided in the institution, are encouraged to make this information available to the public.

Regardless of any institutional policies with respect to MAID, providers who work in institutions must meet the professional referral obligations established by their respective regulatory colleges.

Conscientious objection and obligations

In Ontario, health regulatory colleges are responsible for regulating their respective professions in the public interest. In doing so, colleges may establish policies and standards that their members must comply with, including policies and standards regarding MAID.

The College of Physicians and Surgeons of Ontario’s Professional Obligations and Human Rights policy requires that when physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another healthcare provider must be provided to the person.

An effective referral means “a referral made in good faith, to a non-objecting, available, and accessible physician, other health care professional, or agency.” Referrals must be made in a timely manner.

Similar obligations of nurses, nurse practitioners, pharmacists and pharmacy technicians have been established by their respective regulatory colleges.

If a person has questions about their providers’ professional obligations, they can contact the applicable regulatory college.

Providers must meet the professional obligations established by their respective regulatory colleges. Institutions are encouraged to develop policies with respect to MAID in this context.

Monitoring and reporting MAID

Ontario provides voluntary, standardized clinician aids that reflect the requirements set out in federal legislation. Physicians and nurse practitioners are strongly encouraged to complete the clinician aids in addition to their usual medical record-keeping requirements, as outlined by their regulatory colleges, and keep them on file. Use of these clinician aids is voluntary and can be found on the Government of Ontario’s Central Forms Repository.

Please note that clinician aids do not qualify as a complete eligibility assessment and should be considered supplementary to record keeping requirements established by regulatory colleges.

Reporting deaths from MAID

Under Ontario law, physicians and nurse practitioners who provide MAID are required to notify the Office of the Chief Coroner of the death and provide the Office of the Chief Coroner with the facts and circumstances of the death. This reporting should be done through the Medical Assistance in Dying Death Report, found on the Government of Ontario’s Central Forms Repository.

Once a death is reported, the Office of the Chief Coroner will determine whether it is appropriate to investigate the death. Each case is different, and the Office of the Chief Coroner cannot determine in advance of any death whether an investigation is warranted. The Office of the Chief Coroner cannot provide guidance or recommendations to a provider in advance of a death.

If the Office of the Chief Coroner investigates a MAID death, they are required to complete and sign the medical certificate of death.

However, if the Office of the Chief Coroner is of the opinion that the death does not require an investigation, then, in accordance with applicable law, the physician or nurse practitioner is required to complete and sign the medical certificate of death.

Providers will need to work with the Office of the Chief Coroner to provide the information the office needs to make an informed decision about the investigation. In the event of an investigation, the coroner will only obtain information necessary to fulfill their duties.  Providers should refer to the Process Overview and Checklist for more information on the process for reporting a MAID death and the information and documentation frequently requested by the Office of the Chief Coroner.

Individuals who have chosen to self-administer MAID are encouraged to share their plans and the contact information of their attending provider with a family member/s or friend/s to help ensure authorities are aware that their death was planned.

Federal regulations and Ontario's hybrid approach to the reporting requirements

Federal legislation sets out reporting requirements for MAID. All providers who assess MAID eligibility, and/or any person (such as a nurse, social worker, etc.) who determines that an individual seeking MAID isn’t eligible based on federal eligibility requirements (referred to as a preliminary assessment) will be required to report the preliminary assessment and any information in accordance with the federal Regulations for the Monitoring of Medical Assistance in Dying. Pharmacists and pharmacy technicians are also required to meet federal reporting requirements if they dispense a substance for MAID. Refer to the tables below for more information.

According to federal reporting requirements for MAID any written or verbal request for MAID received on or after November 1, 2018, may trigger reporting requirements. The following health care providers are subject to the federal reporting requirements:

• physicians or nurse practitioners who receive a person's request for MAID and encounter one of the following seven scenarios:
  • MAID was provided by administering a substance to a person
  • MAID was provided by prescribing or providing a substance for self-administration by the person
  • a person was referred to another provider or a care coordination service, or a transfer of care occurred as a result of the request
  • a person was found to be ineligible for MAID
  • the person was found to be eligible for MAID, but the provider subsequently determined that a safeguard had not been met and therefore MAID was not provided
  • the provider becomes aware that the person has withdrawn their request for MAID
  • the provider becomes aware that the person has died from a cause other than MAID
• pharmacists or pharmacy technicians who dispense a substance in connection with the provision of MAID

To minimize the reporting burden on providers, Ontario has developed a hybrid approach  to meet federal reporting regulations.

In cases where a medically assisted death has occurred (provider and self-administered cases), physicians and nurse practitioners are required to report to the Office of the Chief Coroner through the Medical Assistance in Dying Death Report after confirming or becoming aware that the person has died.

The Office of the Chief Coroner will collect information from physicians and nurse practitioners as required, and will report to Heath Canada on their behalf.

In all cases where a request was made, but a medically assisted death has not occurred, physicians and nurse practitioners are required to report to Health Canada directly via the Canadian MAID Data Collection Portal.

This includes cases where a written request was received, but a medically assisted death did not occur (for example, because the patient was ineligible, the patient was referred to another provider, the person withdrew their request for MAID, or the person died from a cause other than MAID). Under these scenarios, the provider has up to 30 calendar days to file a report with Health Canada. The 30 days starts after one of those four events occurs not when the written request is submitted to the provider. If none of the aforementioned events happens within 90 calendar days of the provider receiving the request, the provider is not required to report to Health Canada.

These requirements also apply in cases where a physician or nurse practitioner has provided a prescription for self-administered MAID but a medically assisted death has not occurred (for example, because the patient died from a cause other than MAID, the patient is still alive, or the outcome is unknown). Under these scenarios, the provider must report no earlier than 90 days and no later than 120 days after the prescription or substance is provided. However, if the provider becomes aware of the patient's death from a cause other than MAID in less than 90 days, the provider may report to Health Canada before the 90^th day. If the provider becomes aware of the patient's death from MAID less than 90 days after the prescription or substance is provided, the provider must report to the Office of the Chief Coroner immediately after confirming or becoming aware that the person has died.

In instances where a non-provider conducts a preliminary assessment of a person’s request for MAID and finds them ineligible, this non-provider (referred to as a preliminary assessor) will still be required, under federal reporting regulations, to report the request and their determination of ineligibility to the Canadian MAID Data Collection Portal within 30 days after the day on which the determination of ineligibility is made.

All pharmacists or pharmacy technicians who have dispensed a substance in connection with the provision of MAID are required to report to Health Canada via the Canadian Medical Assistance in Dying Data Collection Portal within 30 days after the day of dispensing.

For more clarity on these requirements please refer to the tables below.

Table 1: The following table provides scenarios where a written request is received and MAID has been provided.

Table 2: The following table provides scenarios where a written request is received and a medically assisted death has not occurred.

Table 3: The following table provides a scenario where a non-provider (preliminary assessor) performs a preliminary assessment for a person for the purposes of MAID

Under Ontario's hybrid reporting approach, there will be duplicative reporting for only a small fraction of self-administered MAID cases that result in a medically assisted death. Duplicative reporting would only occur if a medically assisted death occurred after the 90^th day from when the substance for self-administration was prescribed and the physician or nurse practitioner had already reported to Health Canada.

In this scenario, a physician or nurse practitioner would be required to report to Health Canada between the 90–120 day period stipulated in federal regulations, and then to the Office of the Chief Coroner immediately after becoming aware of the self-administered medically assisted death.

The requirement to provide information for monitoring purposes is triggered by the assessment of MAID eligibility or receipt of a verbal or written request for MAID.

A person's request (verbal or written) may take any form including a text message, an e-mail, or Ontario’s Clinician Aid A.

It must, however, be more than an inquiry or a request for information about MAID.

The request does not have to be in the format required by the Criminal Code as a safeguard when MAID is provided (in other words, it does not need to be duly signed, dated and witnessed) to require reporting.

In cases of a medically assisted death, only the provider who provides MAID must report to the Office of the Chief Coroner. If the first assessor is not the provider who administers MAID, they may need to report a referral (as outlined above) to Health Canada.

Funding for MAID services

Physician and nurse practitioner activities for MAID are funded through existing OHIP billing codes for physician services, and salaried contracts for nurse practitioners.

Existing compensation mechanisms are also employed to compensate pharmacists and other health care professionals involved in the provision of MAID

Virtual care

All medically necessary virtual care services, including services related to the provision of MAID, will continue to be insured under OHIP. Patients will continue to have access to clinically appropriate virtual care, where virtual care is the appropriate modality of service.

MAID resources for medical providers

The Canadian Association of MAID Assessors and Providers (CAMAP)

CAMAP is currently providing a free curriculum for providers (licensed physicians and nurse practitioners), until 2026. The Canadian MAID Curriculum (CMC) is the first nationally accredited, comprehensive, bilingual educational program to support the practice of MAID in Canada. The training is delivered through a combination of online and in-person formats.

The curriculum offers a comprehensive total of 81 credits for the College of Family Physicians of Canada (CFPC) and 27 hours of self-assessment for the Royal College of Physicians and Surgeons of Canada (RCPSC). There are 13 online self-study hours and 14 hours for facilitated sessions.

Health Canada is funding clinician learners to take the curriculum until 2026. All topics in this curriculum are accredited by the RCPSC and the College of Family Physicians of Canada (CFPC).

For more information, please visit CAMAP’s Website.

Centre for Effective Practice (CEP)

CEP provides a comprehensive MAID tool for MAID providers. This resource summarizes the requirements outlined in federal and provincial legislation and guidelines provided by various provincial regulatory colleges, and presents them in a logical, sequential order to to support medical providers and nurse practitioners with patient requests for MAID.

For more information and to access the tool please visit CEP’s website.

Advice to the profession

For more information, clarification, and advice on federal MAID regulations and best practices, please visit the Advice to the Profession: Medical Assistance in Dying webpage.