Approved by Council: June 2016
Reviewed and Updated: June 2016; July 2017; December 2018, April 2021

Companion Resources: Advice to the Profession

Other References:

• Medical Assistance in Dying Resources
• Early Lessons Learned
• Centre for Effective Practice: Medical Assistance in Dying Resource
• Survey: Clinician Registration for the Care Co-ordination Service (CCS) for MAID
• Ministry of Health and Long-Term Care – Medical Assistance in Dying

Definitions

Capacity: A person is capable with respect to a treatment if they are able to understand the information that is relevant to making a decision or lack of decision and able to appreciate the reasonably foreseeable consequences of a decision or lack of decision.¹ Capacity to consent to a treatment can change over time, and varies according to the individual patient and the complexity of the specific treatment decision.

Effective Referral: taking positive action to ensure the patient is connected² to a non-objecting, available, and accessible³ physician, other health-care professional, or agency.⁴ For more information about an effective referral, see the companion Advice to Profession document.

Medical Assistance in Dying (MAID): In accordance with federal legislation, MAID includes circumstances where a medical practitioner or nurse practitioner (“MAID provider”), at an individual’s request: (a) administers a substance that causes an individual’s death; or (b) prescribes a substance for an individual to self-administer to cause their own death.

Medical Practitioner: A physician who is entitled to practise medicine in Ontario, including postgraduate medical trainees.

Nurse Practitioner: A registered nurse who, under the laws of Ontario, is entitled to practise as a nurse practitioner and autonomously make diagnoses, order and interpret diagnostic tests, prescribe substances, and treat patients.

Policy

Federal legislation establishes the legal framework for MAID in Canada, including eligibility criteria and safeguards that must be satisfied prior to providing MAID.^5,6

1. Physicians must manage all requests for MAID in accordance with the legal requirements⁷ and expectations set out in this policy.⁸

Criteria for Medical Assistance in Dying

The federal legislation sets out the criteria that must be met in order for an individual to be eligible to access MAID, along with safeguards that must be met before providing MAID. The eligibility criteria are set out here and in the ‘Process Map’ below, and the safeguards are set out in the ‘Process Map’.

2. Before providing MAID, physicians must be satisfied that the patient meets all of the eligibility criteria set out in federal legislation, which requires that the patient:
   1. be eligible for publicly funded health-services,
   2. be capable and at least 18 years of age,
   3. have a grievous and irremediable medical condition,
   4. make a request for MAID voluntarily and not as a result of external pressure, and
   5. provide informed consent to receive MAID after having been informed of the means available to relieve their suffering, including palliative care.
3. In order to assess the patient against the federal eligibility criteria, physicians must use their professional judgement.

Additional information and expectations relating to each criterion are set out below.

The individual must be eligible for publicly funded health services

4. As the activities involved in assessing patients for and providing MAID are insured services,⁹ physicians must not charge patients directly for MAID or associated activities. Physicians are advised to refer to the OHIP Schedule of Benefits for further information.

The individual must be capable and at least 18 years of age¹⁰

5. Physicians must ensure the patient is able to understand and appreciate the history and prognosis of their medical condition, treatment options, the risks and benefits of their treatment options, and the certainty of death upon self-administering or having a physician administer the fatal dose of medication.
   1. As capacity is fluid and may change over time, physicians must be alert to potential changes in a patient’s capacity.
   2. Physicians are advised to rely on existing practices and procedures for capacity assessments.

The individual’s medical condition must be grievous and irremediable

According to the federal legislation, an individual has a grievous and irremediable medical condition only if:

• they have a serious and incurable illness, disease, or disability that is not a mental illness;¹¹
• they are in an advance state of irreversible decline in capability; and
• their illness, disease, disability, or state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions they consider acceptable.

6. As the definition of grievous and irremediable does not follow terminology typically used in a clinical context, physicians must use their professional judgment when assessing a patient for a grievous and irremediable medical condition.¹²
   1. Physicians are advised to obtain independent legal advice if they are uncertain about whether a patient meets this eligibility criterion.

The individual’s request must be voluntary and not as a result of external pressure

7. Physicians must be satisfied that the patient’s decision has been made freely, without undue influence from family members, health care providers, or others, and that they have made the request themselves, thoughtfully, and in a free and informed manner.

The individual must provide informed consent

8. As MAID can only be provided to a capable adult, physicians must obtain informed consent¹³ directly from the patient, not the substitute decision-maker of an incapable patient.
9. As part of obtaining informed consent, physicians must:
   1. Discuss all treatment options with patients, including the associated risks and side effects, which includes informing patients of means that are available to relieve their suffering, including palliative care.¹⁴
   2. Inform the patient whose natural death is not reasonably foreseeable of the means available to relieve their suffering, including, where appropriate, counselling services, mental health and disability support services, community services and palliative care and offer consultations with relevant professionals who provide those services or that care.
      1. If the MAID provider and other physician or nurse practitioner who confirmed the patient meets the eligibility criteria do not have expertise in the condition that is causing the patient’s suffering, one of them must consult with a physician or nurse practitioner who has that expertise and must share the results of the consultation with the other the second physician or nurse practitioner.
   3. Inform the patient who is indicating a preference for self-administered MAID:
      1. of the potential complications associated with this option, including the possibility that death may not be achieved; and
      2. that should the patient’s death be prolonged or not achieved, it will not be possible for the physician to intervene and administer a substance causing their death unless the patient is capable and can provide consent immediately prior to administering, or the patient has entered into a written arrangement providing advance consent for physician-administered MAID.¹⁵
   4. Inform patients that they may, at any time and in any manner, withdraw their request for MAID, and that patients will be given an opportunity to withdraw their request immediately before MAID is provided.

Final Express Consent to Receiving MAID and Written Arrangements Waiving Final Express Consent

10. In certain circumstances,¹⁶ individuals may enter into written arrangements with a MAID provider that waives the requirement that they give express consent immediately prior to receiving MAID. Physicians must obtain final express consent immediately before providing MAID unless they have entered into a written arrangement with the patient and comply with the steps in provision 11.
11. Physicians must only administer MAID in accordance with a written arrangement waiving the patient’s final express consent in the following circumstances:
    1. The patient’s natural death is reasonably foreseeable and:
       1. before the patient lost capacity to consent to MAID:
          1. the patient met the eligibility criteria and all safeguards relevant for patients whose natural death is reasonably foreseeable;
          2. the patient and the MAID provider entered into a written arrangement that the provider would administer MAID on a specified day;
          3. the patient was informed by the MAID provider of the risk of losing the capacity to consent to receive MAID prior to the day specified in the written arrangement; and
          4. the written arrangement provides the patient’s consent for the provider to administer MAID on or before the day specified in the arrangement if they lose their capacity to consent prior to that day;
       2. the patient has lost the capacity to consent to receiving MAID;
       3. the patient does not demonstrate, by words, sounds or gestures, refusal to have the substance administered or resistance to its administration;^{17, 18} and
       4. the MAID provider administers MAID to the patient in accordance with the terms of the written arrangement.
    2. The patient has chosen self-administered MAID¹⁹ and:
       1. before the patient lost their capacity to consent to receive MAID, the patient and MAID provider entered into a written arrangement that:
          1. states the MAID provider will be present when the patient is self-administering MAID;
          2. provides consent for the MAID provider to administer a second substance causing death if self-administration fails, i.e., if the patient does not die within a specified period and loses their capacity to consent; and
          3. specifies the time period after which the MAID provider may administer the second substance, if self-administration fails;
       2. the patient loses capacity after self-administering MAID and does not die within the time period specified in the written arrangement; and
       3. the MAID provider administers MAID to the patient in accordance with the terms of the written arrangement.

Conscientious Objection

The College recognizes that physicians have the right to limit the health services they provide for reasons of conscience or religion. For clarity, the College does not require physicians who have a conscientious or religious objection to MAID to provide MAID under any circumstances.²⁰

However, physicians’ freedom of conscience and religion must be balanced against the right of existing and potential patients to access care. The Supreme Court of Canada noted, in the Carter²¹ case, that the rights of physicians and patients would have to be reconciled in any regime governing MAID. The Court of Appeal for Ontario has confirmed that where an irreconcilable conflict arises between a physician’s interest and a patient’s interest, physicians’ professional obligations and fiduciary duty require that the interest of the patient prevails.²²

While the federal legislation does not address the conscientious objections of health care providers, the College has outlined expectations, set out below, for physicians who have a conscientious or religious objection to MAID. These expectations accommodate the rights of objecting physicians to the greatest extent possible, while ensuring that patients’ access to health care is not impeded.

12. Consistent with the expectations set out in the College’s Professional Obligations and Human Rights policy, physicians who decline to provide MAID due to a conscientious objection:
    1. must do so in a manner that respects patient dignity and must not impede access to MAID.
    2. must communicate their objection to the patient directly and with sensitivity, informing the patient that the objection is due to personal and not clinical reasons.
    3. must not express personal moral judgments about the beliefs, lifestyle, identity or characteristics of the patient.
    4. must provide the patient with information about all options for care that may be available or appropriate to meet their clinical needs, concerns, and/or wishes and must not withhold information about the existence of any procedure or treatment because it conflicts with their conscience or religious beliefs.
    5. must not abandon the patient and must provide the patient with an effective referral.^23,24
       1. Physicians must make the effective referral in a timely manner and must not expose patients to adverse clinical outcomes due to a delay in making the effective referral.

Involvement of Postgraduate Medical Trainees

13. Postgraduate medical trainees can participate in the MAID process, but must do so within the terms, conditions, and limitations of their certificate of registration.²⁵
14. Postgraduate medical trainees and other physician assessor involved in assessing a patient’s eligibility for MAID must pay particular attention to ensuring that there is independence between the assessors. Specifically, the requirement for independence between the two assessors of a patient’s eligibility for MAID is not satisfied if one assessor is a mentor or supervisor to the other.

Reporting Obligations

Depending on the circumstances, physicians who receive a written request for MAID, conduct an eligibility assessment²⁶ , or provide MAID have reporting obligations to both Health Canada and the Office of the Chief Coroner for Ontario (OCC).

15. When a written request for MAID is received from the patient (in any form, including email or text message, although not necessarily the written request required by the safeguard in the Criminal Code²⁷ ), or an eligibility assessment²⁸ is conducted, and a medically assisted death does not occur, physicians must make a report to Health Canada²⁹ when they:
    1. Find the patient to be ineligible for MAID;
    2. Refer the patient to another practitioner or care coordination service;
    3. Become aware the patient died from another cause;
    4. Become aware the patient withdrew their request for MAID; or
    5. Prescribe a substance for MAID that to their knowledge did not result in a medically assisted death within the prescribed timeframe.
16. Physicians must report any of the situations set out in provision 15 (a-d) to Health Canada within 30 days, with the exception of provision 15 (e), in which case a report must be made between 90 and 120 days after the substance is prescribed. Physicians must make their report using the Canadian MAID Data Collection Portal.³⁰
17. Physicians who provide MAID must report medically assisted deaths to the OCC.^{31, 32}
    1. Physicians must provide the OCC with any information about the facts and circumstances related to the medically assisted death that the OCC considers necessary to form an opinion as to whether the death ought to be investigated. Typically, providing the patient’s medical record pertaining to the medically assisted death will suffice.

Medical Record Keeping

18. Physicians must comply with the expectations set out in the College’s Medical Records Documentation policy In particular, physicians must:
    1. document each physician-patient encounter in the medical record, including encounters relating to MAID, which will include, where indicated:
       1. a focused relevant history;
       2. an assessment and appropriate focused physical exam;
       3. a diagnosis and/or differential diagnosis; and
       4. a management plan, including advice given to patients and/or caregivers;
    2. ensure that the medical record is legible and the information is understandable to other health care professionals; and
    3. ensure that the author of each entry in the medical record is identifiable.
19. Physicians must:
    1. document all oral and written requests for MAID, the dates they were made, and include a copy of the patient’s written request in the medical record;³³
    2. document each element of the patient’s assessment in accordance with the criteria for MAID; and
    3. include a copy of their written opinion in the medical record.
20. Where MAID is provided, physicians must document:
    1. the analysis undertaken to determine whether the patient’s natural death was or was not reasonably foreseeable;
    2. the steps taken to satisfy themselves that the relevant procedural safeguards were met;
    3. the medication protocol used (i.e., drug type(s) and dosages);
    4. the time of the patient’s death; and
    5. any additional information needed to comply with their reporting obligations to the OCC when MAID is provided.
21. Physicians who decline to provide MAID must document that an effective referral was made, the date it was made, and the physician, practitioner, and/or agency to which the referral was made.

Completion of Death Certificate

22. If, after reviewing the report provided, the OCC determines that no investigation is needed, physicians who provided MAID must complete the medical certificate of death.³³
23. When completing the death certificate³⁵ physicians:
    1. must list the illness, disease, or disability leading to the request for MAID as the cause of death; and
    2. must not make any reference to MAID or the drugs administered on the death certificate.

Process Map

The process map that follows details the steps that physicians must undertake in relation to MAID. It complies with federal legislation and outlines safeguards that must be adhered to, by law, prior to the provision of MAID.³⁶

The federal legislation sets out safeguards that must be met before MAID is provided. The applicability of some of the safeguards depend on whether or not the individual’s natural death is reasonably foreseeable. The process map that follows provides an illustration of how MAID may be carried out, from initial patient inquiry to provision, in compliance with the federal legislation.

Nurse practitioners and other professionals are noted in the Process Map only to the extent necessary to reflect relevant provisions of the federal legislation. Expectations for the responsibilities and accountabilities of nurse practitioners, pharmacists and pharmacy technicians, and other health care providers are set by their respective regulatory bodies.

Physicians and nurse practitioners, along with those who support them, are protected from liability if acting in compliance with the federal legislation and any applicable provincial or territorial laws, standards or rules.³⁷

Initial Inquiry for Medical Assistance in Dying

Patient makes initial inquiry for MAID to a physician or nurse practitioner.

Physicians who have a conscientious objection to MAID are not obliged to proceed further through the process map and evaluate a patient’s inquiry for MAID. As described above, objecting physicians must provide the patient with an effective referral to a non-objecting physician, nurse practitioner, or agency. The objecting physician must document, in the medical record, the date on which the effective referral was made, and the physician, nurse practitioner and/or agency to which the patient was connected.

Safeguards for Medical Assistance in Dying

Before physicians provide MAID, they must ensure all relevant safeguards have been adhered to.

The applicability of some of the safeguards depend on whether or not the individual’s natural death is reasonably foreseeable. As such, physicians providing MAID must first determine whether the patient’s natural death is reasonably foreseeable.³⁸ Then, physicians will be able to determine which safeguards apply.

The safeguards set out below apply in all circumstances unless specifically noted.

Physician or nurse practitioner providing MAID (“MAID provider”) assesses the patient against eligibility criteria for MAID.

The MAID provider must ensure that the patient meets the criteria for MAID. As described above, the patient must:

1. Be eligible for publicly funded health services in Canada;
2. Be at least 18 years of age and capable of making decisions with respect to their health;
3. Have a grievous and irremediable medical condition;
4. Make a voluntary request for MAID that is not the result of external pressure; and
5. Provide informed consent to receive MAID after having been informed of the means that are available to relieve their suffering, including palliative care.

Where the patient’s capacity or voluntariness is in question, physicians must refer the patient for a specialized capacity assessment.

With respect to the third element of the above criteria, a patient has a grievous and irremediable medical condition if:

• They have a serious and incurable illness, disease or disability that is not a mental illness;³⁹
• They are in an advanced state of irreversible decline in capability; and
• 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.

If the MAID provider concludes that the patient does not meet the criteria for MAID as outlined above, the patient is entitled to make a request for MAID to another physician or nurse practitioner who would again assess the patient using the above criteria.

The physician must document the outcome of the patient’s assessment in the medical record.

Patient makes written request for MAID before an independent witness.

The patient’s request for MAID must be made in writing. The MAID provider must ensure the written request is signed and dated by the patient requesting MAID on a date after the patient has been informed that they have a grievous and irremediable medical condition.

Physicians are advised that a patient may have been informed that they have a grievous and irremediable medical condition by a physician who is not involved in assessing their eligibility for MAID. The federal legislation does not require that a patient be informed that they have a grievous and irremediable medical condition in the context of an eligibility assessment for MAID.  As long as the patient was informed that their condition is grievous and irremediable before making a formal written request for MAID, these requirements of the federal legislation are met.

If the patient requesting MAID is unable to sign and date the request, another person who is at least 18 years of age,  who understands the nature of the request for MAID, and who does not know or believe that they are a beneficiary under the will of the individual making the request, or a recipient, in any other way, of a financial or material benefit resulting from the patient`s  death, may do so in the patient’s presence, on the patient’s behalf, and under the patient’s express direction.

The MAID provider must ensure the patient’s request for MAID must be signed and dated before an independent witness, who then must also sign and date the request. An independent witness is someone who is at least 18 years of age, and who understands the nature of the request for MAID.

An individual may not act as an independent witness if they are a beneficiary under the patient’s will, or are a recipient in any other way of a financial or other material benefit resulting from the patient’s death; or own or operate the health care facility at which the patient making the request is being treated.

An individual may not act as an independent witness if they are directly involved in providing the patient health care services or personal care, unless they provide health care services or personal care as their primary occupation and are paid to provide that care to the patient. However, the physician or nurse practitioner who conducted an eligibility assessment for MAID, provided a consultation in light of their expertise in the condition causing the patient’s suffering, or who will provide MAID to the patient may not act as an independent witness.

Physicians must document the date of the patient’s request for MAID in the medical record. Additionally, physicians must document the steps taken to satisfy themselves that the patient’s written request for MAID was signed by an independent witness. A copy of the physician’s written opinion regarding whether the patient meets the eligibility criteria must also be included in the medical record.

MAID provider must remind the patient of his/her ability to rescind the request at any time.

The MAID provider must remind the patient that they may, at any time and in any manner, withdraw their request.

MAID provider must 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 if the patient has difficulty communicating.

Another physician or nurse practitioner confirms, in writing, that the patient meets the eligibility criteria for MAID.

The MAID provider must ensure that another physician or nurse practitioner has assessed the patient in accordance with the criteria provided above, and provided their written opinion confirming that the requisite criteria for MAID have been met.

The MAID provider must be satisfied that they and the other physician or nurse practitioner assessing a patient’s eligibility for MAID are independent of each other and of the patient. This means that they must not:

• Be a mentor to, or be responsible for supervising the work of the other physician or nurse practitioner;
• Know or believe that they are a beneficiary under the will of the individual making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that individual’s death, other than standard compensation for their services relating to the request; or
• Know or believe that they are connected to the other practitioner or to the individual making the request in any other way that would affect their objectivity.

If the other physician or nurse practitioner concludes that the patient does not meet the criteria for MAID as outlined above, the patient is entitled to have another physician or nurse practitioner assess them against the criteria.

Additional safeguards where natural death is not reasonably foreseeable

In addition to the safeguards above, physicians must also ensure the following safeguards are met for patients whose natural death is not reasonably foreseeable.⁴⁰

If the MAID provider and other physician or nurse practitioner who confirmed the patient meets the eligibility criteria do not have expertise in the condition that is causing the patient’s suffering, one of them must consult with a physician or nurse practitioner who has that expertise and must share the results of the consultation with the other physician or nurse practitioner.

The MAID provider must ensure the patient has been informed of the means available to relieve their suffering, including, where appropriate: counselling services, mental health and disability support services, community services and palliative care and has been offered consultations with relevant professionals who provide those services or that care.

The MAID provider must ensure that they and the physician or nurse practitioner who confirmed the patient meets the eligibility criteria have discussed with the patient the reasonable and available means to relieve the patient’s suffering and both agree with the patient that the patient has given serious consideration to those means.

The MAID provider must ensure there are at least 90 clear days⁴¹ between the date of the first eligibility assessment for MAID and the date MAID is provided unless both they and the physician or nurse practitioner who confirmed the patient meets the eligibility criteria are of the opinion that the loss of the patient’s capacity to provide consent to receive MAID is imminent and the MAID provider thinks a shorter period is appropriate in the circumstances. Physicians will have to use their professional judgement in determining a shorter period.

Physicians must document the start and end-date of the 90-day assessment period in the medical record, and their rationale for shortening the 90-day assessment period if applicable.

Preparing for Medical Assistance in Dying

MAID includes both situations where the MAID provider writes a prescription for medication that the patient self-administers, and situations where the MAID provider is directly involved in administering a substance to end the patient’s life.

The MAID provider must inform the pharmacist of the purpose for which the substance is intended before the pharmacist dispenses the substance.

Physicians are advised to notify the pharmacist as early as possible that medications for MAID will likely be required. This will provide the pharmacist with sufficient time to obtain the required medications.

Physicians must exercise their professional judgement in determining the appropriate drug protocol to follow to achieve MAID. The goals of any drug protocol for MAID include ensuring the patient is comfortable, and that pain and anxiety are controlled.

Physicians must document the medication protocol utilized (i.e. drug type(s) and dosages) in the medical record.

College members may wish to consult resources on drug protocols used in other jurisdictions.

Providing Medical Assistance in Dying

Immediately before providing MAID, the MAID provider involved must give the patient an opportunity to withdraw the request and if the patient wishes to proceed, confirm that the patient has provided express consent. This must occur either immediately before the medication is administered or immediately before the prescription is provided.

MAID providers can only administer MAID without obtaining final express consent if an eligible patient entered into a written arrangement with the MAID provider waiving this requirement and if the provider administers MAID in accordance with that arrangement, as set out in provision 11.

Where MAID is administered, physicians must document the patient’s time of death in the medical record.

MAID providers and those who assist them throughout the process, are protected from liability if they are acting in compliance with the federal legislation and any applicable provincial or territorial laws, standards or rules. These protections would extend, for example, to pharmacists, any individual who supports a MAID provider (not limited to regulated health professionals), or individuals who aid a patient to self-administer the fatal dose of medication.

Where the patient plans to self-administer the fatal dose of medication at home, physicians must help patients and caregivers assess whether this is a manageable option. This includes ensuring that the patient is able to store the medication in a safe and secure manner so that it cannot be accessed by others, and discussing the option to enter into a written arrangement for the MAID provider to be present when the patient is self-administering in the event it fails so that the MAID provider can provide MAID, as outlined above.⁴²

Further, physicians must ensure that patients and caregivers are educated and prepared for what to expect, and what to do when the patient is about to die or has just died and the physician is not present. This includes ensuring that caregivers are instructed regarding whom to contact at the time of death. For further information, physicians are advised to consult the College’s Planning for and Providing Quality End-of-Life Care policy.

Reporting Requirements and Certification of Death

MAID providers must report the medically assisted death to the Office of the Chief Coroner for Ontario (OCC).^43,44 Upon notification, the OCC will determine whether the death ought to be investigated. If the OCC determines that an investigation is not required, the MAID provider who provided medical assistance in dying completes the death certificate. If the OCC is of the opinion that an investigation is required, the OCC would complete the death certificate.⁴⁵

When completing the death certificate for a medically assisted death, the illness, disease, or disability leading to the request for MAID must be recorded as the underlying cause of death. The death certificate must not make reference to MAID, or the drugs administered to achieve MAID.⁴⁶

Endnotes

^1. Section 4(1) of the Health Care Consent Act, 1996, S.O. 1996, c. 2, Sched. A. (hereinafter HCCA).

^2. An effective referral does not necessarily, but may in certain circumstances, involve a ‘referral’ in the formal clinical sense, nor does it necessarily require that the physician conduct an assessment of the patient to determine whether they are a suitable candidate for the treatment to which they object (in the context of MAID, this means that the physician is not required to assess whether the patient is eligible for MAID prior to making the effective referral).

^3. ‘Available and accessible’ means that the health-care provider must be in a location the patient can access, and operating and/or accepting patients at the time the effective referral is made.

^4. In the hospital setting, practices may vary in accordance with hospital policies and procedures.

^5. The framework was enabled through amendments to the Criminal Code, R.S.C., 1985, c. C-46 (hereinafter, “Criminal Code”).

^6. For more information and resources on MAID, see the Ontario Ministry of Health’s website:  https://www.ontario.ca/page/medical-assistance-dying-and-end-life-decisions

^7. This includes: Sections 241.1-241.4 of the Criminal Code, Regulation for the Monitoring of Medical Assistance in Dying, SOR/2018-166, enacted under the Criminal Code, and Section 10.1 of the Coroners Act, R.S.O. 1990, c. C.37 (hereinafter, “Coroners Act”).

^8. This policy will refer to nurse practitioners and pharmacists, where relevant, in order to reflect the language of the federal law. The policy does not set professional expectations and accountabilities for members of the College of Nurses of Ontario or members of the Ontario College of Pharmacists. For information on the professional accountabilities of nurse practitioners and other members of the College of Nurses of Ontario, please see the College of Nurses of Ontario document titled: Guidance on Nurses’ Roles in Medical Assistance in Dying. For information on the professional accountabilities for members of the Ontario College of Pharmacists, please see the Ontario College of Pharmacists document titled: Medical Assistance in Dying: Guidance to Pharmacists and Pharmacy Technicians.

^9. For example, counselling and prescribing.

^10. This is notably different than Ontario’s HCCA, which does not specify an ‘age of consent’.

^11. Section 241.2 (2.1) of the Criminal Code specifically excludes a mental illness as an illness, disease or disability that makes an individual eligible for MAID. For clarity, an individual suffering solely from a mental illness is not eligible for MAID but an individual with a mental illness may also have a serious and incurable illness, disease, or disability that makes them eligible for MAID provided all of the other eligibility criteria are met. For more information, see the Advice to the Profession document.

^12. Further details on interpreting the statutory definition of a grievous and irremediable medical condition can be found in companion resources authored by the federal government: https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html

^13. The process and requirements for obtaining informed consent in other medical decision-making contexts are also applicable to MAID. More information on consent requirements can be found in the College’s Consent to Treatment policy, which outlines the legal requirements of valid consent as set out in the HCCA, 1996. In particular, in order for consent to be valid it must be related to the treatment, informed, given voluntarily, and not obtained through misrepresentation or fraud.

^14. The College’s Planning for and Providing Quality End-of-Life Care policy sets out the College’s expectations of physicians regarding planning for and providing quality care at the end of life, including proposing and/or providing  palliative care where appropriate.

^15. For more information about self-administration, see provision 11b and the Advice to the Profession document.

^16. Individuals whose natural death is reasonably foreseeable can enter into written arrangements waiving the requirement of final express consent in the event they lose capacity to consent after becoming eligible for MAID. Individuals who choose to self-administer MAID may enter into written arrangements allowing for practitioner-administered MAID in the event of complications following self-administration.

^17. Involuntary words, sounds or gestures made in response to contact do not constitute a demonstration of refusal or resistance.

^18. Once the patient demonstrates, by words, sounds or gestures refusal or resistance MAID can no longer be provided on the basis of the patient’s consent in the written arrangement.

^19. Regardless of whether or not their natural death is reasonably foreseeable.

^20. The College also does not consider a request for MAID to be an emergency.

^21. Carter v. Canada (Attorney General), 2015 SCC 5

^22. See para. 187 Christian Medical and Dental Society of Canada v. College of Physicians and Surgeons of Ontario, 2019 ONCA 393

^23. See the definition of effective referral provided in this policy and the companion Advice to the Profession document for more information and examples of what constitutes an ‘effective referral’.

^24. The Ministry of Health and Long-Term Care has established the Care Coordination Service (CCS) to allow clinicians, patients, and caregivers to access information about MAID and end-of-life care options, and to connect patients with clinicians who provide MAID. Clinicians seeking assistance in making an effective referral can call the CCS toll-free: 1-866-286-4023. If physicians have general questions about the CCS, or wish to register for the CCS as a willing provider, please contact the Ministry of Health and Long-Term Care at [email protected]. The College expects physicians to make reasonable efforts to remain apprised of resources that become available in this new landscape.

^25. Under section 11(8) of Ontario Regulation 865/93, made under the Medicine Act, 1991 (the “Registration Regulation”), the following are terms, conditions and limitations of a certificate of registration authorizing postgraduate education:

1. The holder shall,
   1. Practise medicine only as required by the program in which the holder is enrolled,
   2. Prescribe drugs only for in-patients or out-patients of a clinical teaching unit that is formally affiliated with the department where he or she is properly practising medicine and to which postgraduate trainees are regularly assigned by the department as part of its program of postgraduate medical education, and
   3. Not charge a fee for medical services.

^26. Currently, physicians are only required to report eligibility assessments when they find a patient to be ineligible for MAID. The federal government is amending the Regulations for the Monitoring of MAID to expand reporting requirements to include any assessments of whether a patient meets the eligibility criteria, including preliminary assessments. For more information, see the Advice to the Profession document.

^27. The written request that is required as a safeguard in the Criminal Code must be duly signed, dated, and witnessed. The written request that triggers reporting requirements need not take this form.

^28. See footnote 26.

^29. For more information on physicians’ reporting obligations, including reporting deadlines, please visit the Ministry of Health and Long-Term Care website: http://health.gov.on.ca/en/pro/programs/maid/#regulations

^30. The Canadian MAID Data Collection Portal may be accessed via the Health Canada website: https://www.canada.ca/en/health-canada/services/medical-assistance-dying/guidance-reporting-summary.html.

^31. While the Office of the Chief Coroner for Ontario (OCC) must be notified of all medically assisted deaths, an investigation is not required unless the OCC deems one to be necessary. See Section 10.1(1) of the Coroners Act.

^32. Following the provision of MAID, the physician must notify a coroner by contacting provincial dispatch. Provincial dispatch will then contact the on-duty member of the OCC MAID Review Team, who will obtain information from the reporting physician regarding the facts and circumstances relating to the death.

Documentation pertaining to the medically assisted death is to be faxed, as soon as is reasonably possible, to the MAID review team at 416-848-7791.

^33. The Ministry of Health and Long-Term Care (MOHLTC) has developed clinician aids to support the provision of MAID. These include forms to: (a) assist patients who request MAID (http://bit.ly/29Sovs0); (b) assist physicians who provide MAID (http://bit.ly/2a9M8Pf); and (c) assist physicians who provide a written opinion confirming that the patient meets the eligibility criteria to receive MAID (http://bit.ly/29Spk3Y).

^34. If the OCC initiates an investigation, they will complete a replacement death certificate.

^35. Instructions on completing the Medical Certificate of Death reflect joint guidance developed by the Ministry of Health, the Ministry of Government and Consumer Services, and the Office of the Chief Coroner.

^36. In the event of any inconsistency or conflict between the ‘Process Map’ and the legal requirements set out in the Criminal Code or Regulations, physicians must follow the legal requirements.

^37. Liability protections extend to pharmacists, any individuals supporting physicians or nurse practitioners (not limited to regulated health professionals), and individuals who aid a patient to self-administer the fatal dose of medication, when acting in compliance with the federal legislation and any applicable provincial or territorial laws, standards or rules.

^38. For more information on determining whether or not a patient’s natural death is reasonably foreseeable, see the Advice to the Profession document.

^39. Section 241.2 (2.1) of the Criminal Code specifically excludes a mental illness as an illness, disease or disability that makes an individual eligible for MAID. For clarity, an individual suffering solely from a mental illness is not eligible for MAID but an individual with a mental illness may also have a serious and incurable illness, disease, or disability that makes them eligible for MAID provided all of the other eligibility criteria are met.

^40. For more information on each of these safeguards, see the Advice to the Profession document.

^41. The term “clear days” is defined as the number of days, from one day to another, excluding both the first and the last day.

^42. For more information about self-administration, see the Advice to the Profession document.

^43. Section 10.1(2) of the Coroners Act.

^44. Physicians notify the OCC of a medically assisted death by contacting provincial dispatch. Provincial dispatch will then contact the on-duty member of the OCC MAID Review Team, who will obtain information from the reporting physician regarding the facts and circumstances relating to the death. Documentation pertaining to the medically assisted death is to be faxed, as soon as is reasonably possible, to the MAID review team at 416-848-7791.

^45. Section 21(7) of the Vital Statistics Act, R.S.O. 1990, c. V.4.

^46. Instructions on completing the Medical Certificate of Death reflect joint guidance developed by the Ministry of Health and Long-Term Care, the Ministry of Government and Consumer Services, and the Office of the Chief Coroner.