Health Professionals

Accessing Medical Assistance in Dying

Standards of practice

The following has been adopted by the MAID team, from the College of Physicians and Surgeons of Manitoba’s (CPSM) Standards of Practice and the federal legislation. Any health professional participating in medical assistance in dying MUST be familiar with the requirements as outlined in the legislation and by their respective regulatory bodies.

It is advised that any health professional participating in medical assistance in dying seek legal advice prior to engaging in the provision of this service.

Definitions

The following definitions apply in relation to the provision of medical assistance in dying and do not necessarily apply in other contexts.

Medical assistance in dying - medical intervention by a physician which involves providing or administering pharmaceutical agent(s) that intentionally cause the patient's death at the patient’s request.

Grievous and irremediable medical condition - a person has a grievous and irremediable medical condition only if they meet ALL of the following criteria:

  • they have a serious and incurable illness, disease or disability
  • they are in an advanced state of irreversible decline in capability
  • that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable
  • their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.

Patient - the person requesting medical assistance in dying and whose well-being must be the primary concern of any health professional involved with responding to such a request.

Physician - a member of the CPSM who is registered on the Manitoba Medical Register and who is licensed to practise medicine, excluding a member who is only practising within a residency training program.

Administering Physician – the physician who provides or administers the pharmaceutical agent(s) intended to cause the patient's death. The administering physician is responsible for confirming that all of the requirements outlined by the College of Physicians and Surgeons have been met before the pharmaceutical agent(s) that intentionally cause the patient's death can be provided or administered. There can only be one administering physician for each patient.

Requirements

Key changes, post-legislation, include:

  • Natural death must be reasonably foreseeable

  • MAID is not permitted:

    • Via advance directive

    • To minors

    • Where mental illness is the sole underlying medical condition

  • Requests must be made in writing and signed by two (2) independent witnesses

  • There must be ten (10) clear days between the written request and the day on which MAID is provided

I. Minimum Requirements of All Physicians

A physician must not promote his or her own values or beliefs about medical assistance in dying when interacting with a patient.

On the grounds of a conscience-based objection, a physician who receives a request about MAID may refuse to:

  1. Provide it; or

  2. Personally offer specific information about it; or

  3. Refer the patient to another physician who will provide it.

B. A physician who refuses to refer a patient to another physician or to personally offer specific information about medical assistance in dying on the grounds of a conscience-based objection must:

  1. Clearly and promptly inform the patient that the physician chooses not to provide medical assistance in dying on the grounds of a conscience-based objection, and

  2. Provide the patient with timely access to a resource that will provide accurate information about medical assistance in dying, and

  3. Continue to provide care unrelated to medical assistance in dying to the patient until that physician’s services are no longer required or wanted by the patient or until another suitable physician has assumed responsibility for the patient, and

  4. Make available the patient’s chart and relevant information (i.e., diagnosis, pathology, treatment and consults) to the physician(s) providing medical assistance in dying to the patient when authorized by the patient to do so, and

  5. Document the interactions and steps taken by the physician in the patient’s medical record, including details of any refusal and any resource(s) to which the patient was provided access.

A member who is not a physician and has a conscientious-based objection to MAID who receives a request for MAID, information about MAID or a referral to a physician who will provide MAID must advise the patient making the request that the member has a conscientious-based objection and must communicate the request to the member's supervising physician in a timely fashion.

II. Specific Requirements for Assessing Patient Eligibility for medical assistance in dying

Federal legislation requires that to be eligible for MAID, the patient must meet all of the following criteria:

A. Be eligible for publicly funded health services in Canada

B. Be at least 18 years of age and capable of making decisions with respect to their health;

C. Have a grievous and irremediable medical condition (including an illness, disease or disability);

D. Make a voluntary request for medical assistance in dying that is not the result of external pressure; E. Provide informed consent to receive MAID after having been informed of the means that are available to relieve the patient's suffering, including palliative care.


According to the federal legislation, a person has a grievous and irremediable medical condition only if all of the following criteria are met:

A. They have a serious and incurable illness, disease or disability;

B. They are in an advanced state of irreversible decline in capability;

C. That illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and

D. Their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.

The College requires that:

A. Any physician who conducts an assessment for the purpose of determining if a patient is eligible for MAID pursuant to these requirements must:

  1. Be satisfied that the patient seeking MAID has a grievous and irremediable medical condition which the physician has verified by:

    • Clinical diagnosis of the patient's medical condition; and

    • A thorough clinical assessment of the patient which includes consideration of all relevant, current and reliable information about the patient's symptoms and the available medical treatments to cure the condition or alleviate the associated symptoms which make the condition grievous, including, where appropriate, consultation with another qualified physician;

  2. Be fully informed of the current relevant clinical information about the patient and his/her condition;

  3. Be qualified to render a diagnosis and opine on the patient's medical condition or be able to consult with another physician with relevant expertise for the limited purpose of confirming the diagnosis, prognosis or treatment options;

  4. Use appropriate medical judgment and utilize a reasonable method of assessment;

  5. When assessing whether a patient's illness, disease or disability or state of decline causes the patient enduring physical or psychological suffering that is intolerable to the patient and cannot be relieved under conditions that the patient considers acceptable, ensure that:

    • The unique circumstances and perspective of the patient, including his/her personal experiences and religious or moral beliefs and values have been seriously considered;

    • The patient is properly informed of his/her diagnosis and prognosis in relation to the current or impending associated symptoms; and

    • Treatment options described to the patient include all reasonable medical treatments to cure the condition or alleviate the associated symptoms which make it grievous or, if the patient is terminal, palliative care interventions; and the patient adequately understands the:

      • Current and anticipated course of physical symptoms, ability to function and pain and suffering specific to that patient; and

      • Effect that any progression of physical symptoms, further loss of function or increased pain may have on that specific patient; and

      • Available treatments to manage the patient's symptoms or loss of function or to alleviate his/her pain or suffering.

B. Each physician must document in the patient's medical record all information that is relevant to his/her role and findings in respect to each of the specific requirements of any assessment related to the patient's eligibility for MAID.  

 

III. Specific Requirements for Assessing Medical Decision Making Capacity

A. Any physician who conducts an assessment of a patient for the purpose of determining if the patient is capable of making decisions with respect to their health pursuant to the federal requirements must be:

  1. Fully informed of the current relevant clinical information about the patient and his/her mental and physical condition; and

  2. Qualified to assess competence in the specific circumstances of the patient whose capacity is being assessed or be able to consult with another physician with relevant expertise for the limited purpose of assessing the patient's medical decision making capacity.

B. In the event that a physician has a reasonable doubt as to the patient's competence, an additional independent assessment must be conducted by another physician who is enrolled on the Specialist Register as a psychiatrist.

C. Each physician must document in the patient's medical record all information that is relevant to his/her role and findings in respect to each of the specific requirements of any assessments of a patient's medical decision making capacity.  

 

IV. Specific Requirements for Obtaining Informed Consent

The federal legislation requires that before a physician provides MAID, the physician must:

A. Ensure that the request for MAID was:

1. Made in writing and signed and dated by:

    • The patient; or

    • Where the patient is unable to sign and date the request, by another person (proxy) at the express direction of and in the presence of the patient. The person who serves as the proxy must:

      • Be at least 18 years of age;

      • Understand the nature of the request for MAID;

      • 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 the patient's death; and

      • Be signed and dated after the patient was informed by a physician that the patient has a grievous and irremediable medical condition.

    B. Be satisfied that the request was signed and dated by the patient or by the patient's proxy before two independent witnesses who then also signed and dated the request;
    C. Ensure that the person has been informed that they may, at any time and in any manner, withdraw their request;
    D. Ensure that another physician has provided a written opinion confirming that the person meets all of the eligibility criteria and be satisfied that they and the other physician providing the opinion are independent in that each of them :

    • Is not a mentor to the other practitioner or responsible for supervising their work;

    • 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, other than standard compensation for their services relating to the request; or

    • Does not know or believe that they are connected to the other practitioner or to the patient in any other way that would affect their objectivity;

    E. Ensure that there are 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 provided or — if they and the other physician or nurse practitioner are both of the opinion that the patient's death, or the loss of their capacity to provide informed consent, is imminent — any shorter period that the first physician considers appropriate in the circumstances;
    F. Immediately before providing MAID, give the patient an opportunity to withdraw their request and ensure that the patient gives express consent to receive MAID; and
    G. If the patient has difficulty communicating, take all necessary measures to provide a reliable means by which the patient may understand the information that is provided to them and communicate their decision.


    The federal legislation also provides that any person who is at least 18 years of age and who understands the nature of the request for MAID may act as an independent witness, except if that person:
    A. Knows 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 the patient's death;
    B. Are an owner or operator of any health care facility at which the patient is being treated or any facility in which patient resides;
    C. Are directly involved in providing health care services to the patient; or
    D. Directly provide personal care to the patient.


    The College requires that:
    A. Physicians who obtain informed consent for MAID must have sufficient knowledge of the patient's condition and circumstances to ensure that:

      1. the patient is properly informed of his/her diagnosis and prognosis in relation to the current or impending associated symptoms; and

      2. the treatment options described to the patient include all reasonable medical treatments to cure the condition or alleviate the associated symptoms which make it grievous and/or palliative care interventions where the patient is terminal; and

      3. the patient is offered appropriate counseling resources; and

      4. the patient fully understands that:

      • death is the intended result of the pharmaceutical agent(s); and

      • the potential risks and complications associated with taking the pharmaceutical agent(s).

    B. Each physician who obtains informed consent from the patient for MAID must:
    1. have either conducted his/her own assessment or be fully informed of the assessments conducted by other physicians of the patient's medical condition and the patient's medical decision making capacity; and

    2. Meet the legal requirements for informed consent, including informing the patient of:

      a. Material information which a reasonable person in the patient's position would want to have about MAID;
      b. The material risks associated with the provision/administration of the pharmaceutical agent(s) that will intentionally cause the patient's death; and

    3. Meet with the patient alone at least once to confirm that his/her decision to terminate his/her life by MAID is voluntary and that the patient has:

      a. Made the request him/herself thoughtfully; and

      b. A clear and settled intention to end his/her own life by MAID after due consideration;

      c. Considered the extent to which the patient has involved or is willing to involve others such as family members, friends, other health care providers or spiritual advisors in making the decision or informing them of his/her decision; and

      d. Made the decision freely and without coercion or undue influence from family members, health care providers or others.

    C. Each physician must document in the patient's medical record all information that is relevant to his/her role and findings in respect to each of the specific requirements for obtaining informed consent.

     

    V. Additional Requirements of the Federal Legislation

    The federal legislation also:
    A. Requires physicians who receive a written request for MAID to provide information pursuant to regulations made by the Minister of Health;
    B. Requires that physicians who, in providing MAID, prescribe or obtain a substance for that purpose must, before any pharmacist dispenses the substance, inform the pharmacist that the substance is intended for that purpose;
    C. Requires physicians to comply with guidelines established for the completion of certificates of death for patients to whom MAID is provided;
    D. Creates criminal offences for knowingly failing to comply with the eligibility and safeguard requirements set out in Criminal Code and destroying documents with the intent to interfere with a patient's access to MAID, the assessment of a request for MAID or a person seeking an exemption related to MAID.

    The College expects physicians to comply with the federal and provincial regulations and guidelines described above as they come into force and effect. 

     

    VI. Specific Requirements of the Administering Physician

    A.The administering physician must:

    1. Have appropriate knowledge and technical competency to provide/administer the pharmaceutical agent(s) in the appropriate form and/or dosage that will terminate the patient’s life in the manner in which the patient was informed that it would terminate his/her life at the time the patient provided his/her consent; and

    2. Be qualified to provide appropriate instructions to the patient as to how to administer the pharmaceutical agent(s) that will terminate the patient’s life in the manner in which the patient was informed that it would terminate his/her life at the time the patient provided his/her consent in circumstances where the patient elects to administer the pharmaceutical agent(s) to him/herself; and

    3. Be readily available to care for the patient at the time the pharmaceutical agent(s) that intentionally brings about the patient's death is administered by the administering physician or taken by the patient until the patient is dead; and

    4. Provide reasonable notice to the Office of the Chief Medical Examiner that the patient is planning to die by means of medical assistance in dying where the location is not a health care institution; and

    5. Certify, in writing, on the prescribed form that he/she is satisfied on reasonable grounds that all of the following requirements have been met:

      1. The patient is at least 18 years of age;

      2. The patient’s medical decision making capacity to consent to receiving medication that will intentionally cause the patient's death has been established in accordance with the requirements of the Criminal Code and the CPSM bylaw;

      3. All of the requirements of the Criminal Code and the CPSM bylaw in relation to assessing eligibility for MAID and obtaining and documenting informed consent have been met; and

    6. Ensure that the requirements of physicians set out in all relevant federal and provincial legislation, including the Criminal Code, The Fatality Inquiries Act, C.C.S.M. c. F52 and The Vital Statistics Act, C.C.S.M. c. V60 in respect to reporting and/or registering the cause and manner of the patient's death, including completing all required forms specified by the legislation or regulations, are met in a timely fashion.