1. Introduction
On June 17, 2016, Bill C-14, the legislation on medical assistance in dying, received royal assent.1
2. Criteria for Medical Assistance in Dying (MAID)
In Canada, only physicians and nurse practitioners can legally provide MAID. There are two ways of providing this service:2,3
1) the physician or nurse practitioner directly administers a substance causing death
2) the physician or nurse practitioner gives or prescribes a self-administered drug that causes death
The following conditions must be met in order to be eligible for MAID.2,3 You must:
1) be eligible for government-funded health services
2) be at least 18 years of age and capable of making health-related decisions
3) have a grievous and irremediable medical condition
4) make a voluntary request for MAID which is free from external pressure or influence
5) provide informed consent to receive MAID. This involves obtaining information about your medical diagnosis, the types of treatment available and options to relieve suffering which includes palliative care
The definition of a grievous and irremediable medical condition as stated in Bill C-14 is as follows.3 You must:
1) have a serious and incurable illness, disease or disability
2) be in an advanced state of irreversible decline in capability
3) endure physical or psychological suffering as a result of your illness, disease, disability or state of decline that is intolerable and cannot be relieved under conditions you consider acceptable
4) be at a point where your natural death, taking into account all your medical circumstances, has become reasonably foreseeable. A prognosis does not necessarily have to be made with regards to the specific length of time you have remaining
Note that people with a mental illness are eligible for MAID as long as all of the conditions are met. However, you are not eligible for this service if any of the following applies:2
1) You suffer only from a mental illness
2) Death is not reasonably foreseeable, considering all of your medical circumstances
3) Your mental illness decreases your ability to make decisions regarding your health
At present, the federal government does not allow mature minors or those suffering only from mental illnesses to access MAID. Advance requests are also not accepted. However, the government will be studying these issues in more depth. Independent studies will be initiated within 180 days of the legislation being passed.1
3. Process for Requesting MAID
In order to request MAID, you must complete the following steps:2,3
1) Discuss end-of-life care options in relation to your medical condition and circumstances with your physician or nurse practitioner
2) Your physician or nurse practitioner must conclude that your medical condition is grievous and irremediable and they must ensure that you are eligible to receive MAID based on the criteria above
3) You must sign and date a written request for MAID
4) Your request must be signed and dated by 2 independent witnesses. An independent witness must be at least 18 years of age and understand the nature of the request for MAID. To be considered independent, the witnesses cannot:
• Benefit from your death
• Own or operate a health care facility where you live or are being treated
• Be directly involved in providing you with health care services or personal care
5) A second physician or nurse practitioner must provide a written second opinion that confirms your eligibility for MAID. He or she must be independent from the person providing the original assessment. Being independent means that neither of them:
• Mentors or supervises the other’s work
• Is knowingly benefitting from your death
• Is knowingly connected to the other or to you in a way which would affect their objectivity
6) There must be a minimum 10 day wait period between signing your request and when the service is provided. There may be an exception if:
• Your death is imminent
• Your capacity to provide informed consent will soon be lost
Note that you may rescind your request for MAID at any time and in any manner.
4. Guidelines for Physicians
When determining whether the patient has the capacity to consent to treatment, the physician must ensure that the patient can understand and appreciate the information relevant to making the decision and the reasonably foreseeable consequences of that decision. The patient must be able to understand and appreciate the history and prognosis of their medical condition, their treatment options and the risks and benefits of each one. When requesting MAID specifically, the patient must be able to understand and appreciate that the result of self-administering or having the physician administer the fatal dose of medication is death.4
In determining whether the patient has a grievous and irremediable medical condition, physicians are to use their professional judgement. Physicians may also opt to seek independent legal advice.4
To ensure that the patient is providing informed consent, physicians must review all treatment options with them. The federal legislation specifically requires that the patient be informed of the ways in which their suffering can be relieved, including palliative care. Consent to MAID must be given by an individual who is capable of making decisions and not by a substitute decision maker.4
Physicians who have a conscientious objection to providing MAID and who decline to do so are expected to provide the patient with an effective referral, meaning a referral to a “non-objecting, available and accessible physician, nurse practitioner or agency.” To allow the patient access to MAID, the referral must be made in a timely manner.4
If the first or the second physician decides that the patient does not meet the criteria, the patient is entitled to seek out another physician to request for MAID. That physician will assess them using the same criteria.4
For patients who have met all of the criteria, the physician must ensure that the patients are capable both at the time of the request for MAID and at the time they receive MAID. Just before providing MAID, the physician must give them the opportunity to withdraw their request.4
5. Legislation Facing Legal Challenges
On June 27, 2016, a 25 year old B.C. woman with spinal muscular atrophy and the British Columbia Civil Liberties Association launched a constitutional challenge against the federal government’s assisted-dying legislation. They argue that the legislation is unconstitutional because it deliberately excludes those who are suffering, but whose deaths are not reasonably foreseeable.5
Justice Minister Jody Wilson-Raybould has stated that the government “is aware of this potential challenge and will respond in the courts as appropriate.”5
References
1. Government of Canada, Department of Justice. Medical assistance in dying: Questions and answers [Internet]. 2016 [cited 2016 Jul 8]. Available from: http://www.justice.gc.ca/eng/cj-jp/ad-am/faq.html
2. Government of Canada. Medical assistance in dying [Internet]. 2016 [cited 2016 Jul 8]. Available from: http://healthycanadians.gc.ca/health-system-systeme-sante/services/palliative-pallatifs/medical-assistance-dying-aide-medicale-mourir-eng.php
3. Parliament of Canada. Bill C-14: An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) [Internet].2016 [cited 2016 Jul 8]. Available from: http://www.parl.gc.ca/HousePublications/Publication.aspx?Language=E&Mode=1&DocId=8384014
4. The College of Physicians and Surgeons of Ontario. Medical assistance in dying [Internet]. 2016 [cited 2016 Jul 8]. Available from: http://www.cpso.on.ca/Policies-Publications/Policy/Interim-Guidance-on-Physician-Assisted-Death
5. Laanela M. Assisted-dying legislation faces new legal challenge in B.C. CBC News [Internet]. 2016 Jun 27 [cited 2016 Jul 8]. Available from: http://www.cbc.ca