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Advice to the Profession: Medical Assistance in Dying

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Advice to the Profession companion documents are intended to provide physicians with additional information and general advice in order to support their understanding and implementation of the expectations set out in policies. They may also identify some additional best practices regarding specific practice issues.

Updated October 2020, April 2021

Historically, it was a crime in Canada to assist another person to end their own life. This criminal prohibition applied to circumstances where a physician provides or administers medication that intentionally brings about a patient’s death, at the request of the patient.

However, in the case of Carter v. Canada,1 the Supreme Court of Canada (SCC) determined that the criminal prohibition on medical assistance in dying (MAID) violates the Charter rights of competent adults, who are suffering intolerably from grievous and irremediable medical conditions, and seek assistance in dying. The federal government subsequently enacted legislation on June 17, 2016, through amendments to the Criminal Code, to establish a federal framework for MAID in Canada.

In September 2019, the Superior Court of Quebec struck down one of the eligibility requirements for accessing MAID in Canada, namely, the requirement that a person’s natural death be reasonably foreseeable. While the Court decision only applied in Quebec, the federal government changed the law at the federal level in response to this decision. Bill C-7, an Act to amend the MAID provisions in the Criminal Code, came into force on March 17, 2021.

The Medical Assistance in Dying policy, including the ‘Process Map’ contained within the policy, sets out physicians’ legal and professional obligations regarding MAID. This companion Advice document focuses on the expectations that relate to the new legal framework for MAID (as of March 17, 2021) and the existing expectations regarding effective referrals.

What are the key changes to the legal framework for MAID that came into force March 17, 2021?

The most significant change is that it is no longer necessary for an individual’s natural death to be reasonably foreseeable in order for them to be eligible for MAID. Instead, whether an individual’s natural death is reasonably foreseeable is the determining factor as to which procedural safeguards apply. There is now a two-track approach to procedural safeguards based on whether or not an individual’s natural death is reasonably foreseeable:

  • Existing safeguards have been maintained or eased for individuals whose natural death is reasonably foreseeable.2 For example, this includes reducing the number of independent witnesses required to sign the individual’s written request and eliminating the 10-day reflection period.
  • New and strengthened safeguards have been established for individuals whose natural death is not reasonably foreseeable. For example, this includes requiring that individuals are informed of available and appropriate means to relieve their suffering and are offered consultations with professionals who provide those services. It also requires that individuals undergo a 90-day assessment period before receiving MAID.3

For a complete list of the key changes, which came into force on March 17, 2021, see the Department of Justice’s and Government of Canada’s websites.

What legislation applies if an individual signed and dated their request for MAID before the legislation was amended?

If an individual signed and dated their request for MAID before the amended federal legislation came into force on March 17, 2021, the MAID provider must comply with the legislation that was in place before the amendments.4 There are two exceptions to this:

  • There is no more 10-day waiting period in cases where the individual’s natural death is reasonably foreseeable; and
  • The amendments relating to written arrangements waiving the requirement of final express consent (for individuals whose natural death is reasonably foreseeable and for individuals who are pursuing self-administration) apply regardless of when the individual signed and dated their request for MAID.5

If an individual signed and dated their request for MAID before the amended federal legislation came into force on March 17, 2021, and the individual was assessed but did not qualify because their natural death was not reasonably foreseeable, the individual will have to make a new request and be assessed under the new legal framework in order to be eligible.

What is a grievous and irremediable medical condition?

An individual must have a grievous and irremediable medical condition to be eligible for MAID. As set out in the federal legislation,6 an individual has a grievous and irremediable medical condition if:

  1. They have a serious and incurable illness, disease or disability that is not a mental illness;7
  2. They are in an advanced state of irreversible decline in capability; and
  3. 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.

Further details on interpreting the statutory definition of a grievous and irremediable medical condition can be found in the companion resources developed by the federal government.

Could an individual with a mental illness potentially meet the criteria for MAID? What will I need to consider when determining whether a patient’s condition is solely a mental illness?

The Criminal Code presently excludes mental illness as an illness, disease or disability that makes an individual eligible for MAID.8 This exclusion remains in place until March 17, 2023, at which time it will be repealed.9 The temporary exclusion of mental illness as a medical condition that makes an individual eligible for MAID will provide the federal government with more time to study how MAID can safely be provided to individuals whose only illness is mental illness.10

In the interim, however, individuals with mental illness are not prevented from accessing MAID if they also have a serious and incurable illness, disease, or disability that is not a mental illness and meet the other eligibility criteria for MAID, as set out in the federal legislation. This includes the requirement that the individual who is seeking MAID has decision-making capacity.

Physicians will need to use their professional judgement to determine whether or not the serious and incurable illness, disease or disability, on the basis of which the patient is requesting MAID, is solely a mental illness and therefore does not meet the eligibility criteria. In determining whether a patient’s condition is a “mental illness”, on the sole basis of which they will not be eligible for MAID, physicians may want to consult the guidance provided by the federal government. The Department of Justice has indicated that “mental illness” includes conditions that are primarily within the domain of psychiatry, such as depression and personality disorders, but does not include neurocognitive and neurodevelopmental disorders, or other conditions that may affect cognitive abilities.11

To help physicians demonstrate compliance with the Criminal Code, physicians are required to document each element of the patient’s assessment in accordance with the criteria for MAID, including what serious and incurable illness, disease or disability they have that qualifies them for MAID. It would be helpful for physicians to specifically note how they came to the determination that the patient’s illness is not solely a mental illness.

Can requests for MAID be made through an advance directive or the patient’s substitute decision-maker? Is final express consent required immediately before MAID is provided?

All requests for MAID must be made directly by the patient,12 and cannot be made through an advance directive or by the patient’s substitute decision-maker. The federal legislation specifies that MAID is available only to individuals who are capable of making decisions with respect to their health.13

However, the recent legislative changes now permit individuals to enter into a written arrangement that waives the requirement that the MAID provider obtain their final express consent immediately prior to administering MAID in the following circumstances:

  1. 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. Physicians may administer MAID without obtaining final express consent, in accordance with the waiver set out in the written arrangement, if:
    • before the patient lost capacity to consent to MAID:
      • the patient met the eligibility criteria and all safeguards relevant for patients whose natural death is reasonably foreseeable;
      • the patient and the MAID provider entered into a written arrangement that the provider would administer MAID on a specified day;
      • 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
      • 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;
    • the patient has lost the capacity to consent to receiving MAID;
    • the patient does not demonstrate, by words, sounds or gestures, refusal to have the substance administered or resistance to its administration;14, >15 and
    • the substance is administered to the patient in accordance with the terms of the written arrangement.16
  2. 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. Physicians may administer MAID to a patient who loses the capacity to consent after self-administering if:
    • before the patient lost their capacity to consent to receive MAID, the patient and MAID provider entered into a written arrangement that:
      • states the MAID provider will be present when the patient is self-administering MAID;
      • 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
      • specifies the time period after which the MAID provider may administer the second substance, if self-administration fails;
    • the patient loses capacity after self-administering MAID and does not die within the time period specified in the written arrangement; and
    • the MAID provider administers MAID to the patient in accordance with the terms of the written arrangement.17

The federal government has provided the following clarifications regarding written arrangements that waive the MAID provider’s obligation to obtain final express consent prior to administering MAID:18

  • When entering into a written arrangement to provide MAID on a specified date, there is no legislative limit on how far in the future this date may be. However, individuals are only eligible for MAID if their suffering is intolerable. If an individual is willing to carry on for an extended period of time, this may give rise to questions about whether their suffering is tolerable such that they may not presently be eligible.
  • If the individual or MAID provider postpones the date for the provision of MAID, they must enter into a new written arrangement specifying the new date for provision in order for the waiver to be valid.
  • The federal legislation permits individuals to consent to receiving MAID sooner than the date specified in the written arrangement if they lose capacity before that date. If the individual wishes to have this option available, it is important for them to establish parameters for what they want to happen if they lose capacity prior to the specified date and how the new date of provision is to be determined.
    • The individual and MAID provider will have to discuss the various potential scenarios, including scenarios that might result in an acute loss of capacity, and the MAID provider will need to document the individual’s wishes in the written arrangement.
    • To the degree possible, would be preferable to include the individual’s family/loved ones in the discussion or to inform them of what was discussed in order to avoid potential conflicts regarding the day of MAID provision.
  • The federal legislation does not prohibit individuals from specifying alternate practitioners to provide MAID, should the patient’s initial choice of MAID provider suddenly become unavailable. However, only a practitioner who has personally assessed the individual and found them eligible for MAID while they still retained capacity to provide informed consent may administer MAID. In addition, any practitioner who provides MAID in accordance with a written arrangement waiving the patient’s final express consent must have done the following: agreed to enter into this arrangement with the individual, be listed in the arrangement, and signed the document.
  • The written arrangement does not impose any legal duty on the practitioner to provide MAID if they change their mind and no longer want to provide it.

When is the written arrangement waiving final express consent invalidated?

The federal legislation sets out that the written arrangement waiving final express consent made by a patient whose natural death is reasonably foreseeable is invalidated (permanently) if “a person demonstrates, by words, sounds or gestures, refusal to have the substance administered or resistance to its administration”.19 Consequently, a MAID provider may only administer MAID in accordance with a written arrangement waiving final consent if they are satisfied that the patient has not demonstrated refusal or resistance to administration20 and that any words, sounds or gestures made by the patient are involuntary reactions made in response to contact.21 The federal government has stated that the legislation does not provide any further direction and physicians will have to use their professional judgment to determine whether an individual’s reaction indicated refusal or resistance to administration or was an involuntary reaction in response to contact.22

To help physicians demonstrate compliance with the Criminal Code, it will be essential that physicians document any words, sounds or gestures made by the patient when the MAID provider attempts to administer MAID in accordance with a written arrangement, and their rationale for determining whether or not the patient’s reaction indicated refusal or resistance to administration or was an involuntary reaction in response to contact.

Is it necessary for the MAID provider to be present when the patient is self-administering MAID?

The federal legislation does not require that the MAID provider be present unless they have entered into a written arrangement that permits the physician to provide MAID if the patient does not die within a specified period after self-administering a substance and has lost capacity to provide consent.

Given the risk of potential complications with self-administration, including the possibility that death might not be achieved, the MAID provider may want to encourage the patient to include them among those present during the self-administration even if there is no written arrangement. However, the MAID provider will have to explain that if there is no written arrangement, they cannot intervene and administer a second substance causing death if self-administration is prolonged or fails unless the patient is capable and can provide consent immediately prior to the provider administering MAID.

The applicability of some of the safeguards for MAID depend on whether or not the individual’s natural death is reasonably foreseeable. How do I determine this?

The recent legislative changes have not altered the meaning of “reasonably foreseeable natural death”. Physicians can continue to rely on the guidance previously provided by the federal government and court to inform their assessment of whether a patient’s natural death is reasonably foreseeable or not and therefore which procedural safeguards apply.

The guidance previously provided by the federal government is that an individual’s condition does not have to be fatal or terminal in order for their natural death to be considered reasonably foreseeable.23 Rather, an individual’s natural death is reasonably foreseeable if there is a real possibility of death, evidenced by the individual’s irreversible decline, within a period of time that is foreseeable in the not-too-distant future.24 The federal government advises that the nature of the illness causing the individual intolerable and enduring suffering, and any other medical conditions or health-related factors such as age and/or frailty, are to be considered in assessing the individual’s trajectory towards death.25

The federal government has clarified that “reasonably foreseeable natural death” can result from a combination of multiple factors relevant to an individual’s overall medical circumstances. It is important to acknowledge that anticipating how long an individual has to live is difficult, and clinical estimation of life expectancy becomes even more difficult the further away death is expected.26

The guidance previously provided by the court27 regarding the meaning of “reasonably foreseeable natural death” is as follows:

 [...] natural death need not be imminent and that what is a reasonably foreseeable death is a person-specific medical question to be made without necessarily making, but not necessarily precluding, a prognosis of the remaining lifespan. Although it is impossible to imagine that this exercise of professional knowledge and judgment will ever be easy, in those cases where a prognosis can be made that death is imminent, then it may be easier to say that the natural death is reasonably foreseeable. Physicians, of course have considerable experience in making a prognosis, but the legislation makes it clear that in formulating an opinion, the physician need not opine about the specific length of time that the person requesting medical assistance in dying has remaining in his or her lifetime.

To help physicians demonstrate compliance with the Criminal Code, it will be essential that physicians document the analysis they undertook to determine whether the patient’s natural death was reasonably foreseeable or not.

What does it mean to have “expertise” in the condition that is causing the individual’s suffering? What role does the “expert” play?

A new safeguard in place for individuals whose natural death is not reasonably foreseeable is the requirement that one of the two practitioners who confirm the individual’s eligibility for MAID have expertise in the condition that is causing their suffering, or that they consult with a physician or nurse practitioner who has such expertise.28

The federal government has clarified that the expertise must be in the condition that is causing the individual the greatest suffering.29 A practitioner does not need to have a specialty designation or certification in order to be considered an expert in the individual’s condition.30 Expertise regarding the condition could be obtained through education and training or experience (e.g., treating patients with a similar condition).31 If the condition causing the individual’s unbearable suffering is within the practitioner’s scope of practice, and the practitioner has the knowledge, skill and judgment to treat that condition, including being aware of reasonable and available treatments that may relieve that suffering, they could be considered to have the necessary “expertise”.32

If consultation with a practitioner with expertise is required (because neither of the practitioners who are assessing the individual’s eligibility for MAID have expertise in the condition causing the patient’s greatest suffering), the federal government has clarified that the expert would not be assessing the individual’s eligibility for MAID. Instead, they would conduct a thorough assessment of the individual’s status and treatment options, especially as it relates to options to reduce suffering, and provide advice regarding the reasonable and available services and/or treatment options that might relieve the individual’s suffering. This may include advising on the nature or stage of the individual’s condition or on the status of the individual’s state of decline based on their knowledge of the trajectory associated with the condition. The information provided by the practitioner with expertise enables the practitioners who are assessing the individual’s eligibility for MAID to complete a fully informed assessment of the individual.33

The federal government has also advised that the assessment information will need to be provided by the practitioner with expertise in writing, so both practitioners who are assessing the individual’s eligibility for MAID will have access to it in its entirety.34 To help physicians demonstrate compliance with the Criminal Code, it will be essential that physicians retain the written assessment provided by the practitioner with expertise as part of the patient’s medical record.

What steps do I have to take to inform the patient of the means available to relieve their suffering? How do I satisfy myself that the patient has “given serious consideration” to the reasonable and available means to relieve their suffering?

For individuals whose natural death is not reasonably foreseeable, the federal legislation requires that MAID providers inform individuals of the means available to relieve their suffering, including, where appropriate, counselling services, mental health and disability support services, community services and palliative care.35 Individuals must be offered consultations with relevant professionals who provide those services or that care.36 Both the MAID provider and the second practitioner who confirmed the individual’s eligibility for MAID must discuss these options with the individual and agree that the individual has given serious consideration to the reasonable and available means to relieve their suffering.37

The federal government has clarified that the MAID provider is responsible for providing the individual with a description of the reasonable and available services and/or treatments and their potential impact, and offering the individual consultations with relevant professionals who provide these services and/or treatments. The services and treatments discussed with the individual will be informed by the MAID provider’s consultation with an expert in the patient’s condition.38

The federal government has noted that the federal legislation does not specify a timeline within which the referral to these services and/or treatment must take place. If the individual expresses interest in accessing services and/or treatments which may relieve their suffering, but it will take significant time to access them, the federal government advises MAID providers to take great care in assessing the voluntariness and informed consent of the individual’s request for MAID if they proceed as a result of the length of time it is taking to obtain those other services and/or treatments.39

Ultimately, physicians will need to use their professional judgement to determine whether or not the patient has “given serious consideration” to the reasonable and available means to relieve their suffering. In doing so, physicians may want to consider asking the patient about their thought process (e.g., which services and/or treatments they considered, what they learned about each service or treatment including the expected risks and benefits, can they appreciate the reasonably foreseeable consequences of accessing each service or treatment, etc.). The federal government has clarified that the individual is not required to have tried the services and/or treatment.40

To help physicians demonstrate compliance with the Criminal Code, it will be essential that physicians document the steps taken to satisfy themselves that the relevant procedural safeguards were met, including the nature of the reasonable and available means to relieve the patient’s suffering, that these means were discussed with the patient, and the physician’s rationale for concluding that the patient gave serious consideration to the these means.

How is “90 clear days between the date of the first eligibility assessment for MAID and the date MAID is provided” calculated?

The federal government has clarified that the beginning of the 90-day assessment period is the day on which the first assessment of whether the patient meets the MAID eligibility criteria begins (e.g., the day on which the MAID provider first considers or reflects on information that forms part of a MAID assessment, such as reviewing the patient’s file or meeting with the patient).41

To help physicians demonstrate compliance with the Criminal Code, it will be essential that physicians document the start of the 90 clear days, and if the period is shortened in accordance with the federal legislation, the reasons for doing so and the start and end dates of the new time period.

Can assessments of patient eligibility or witnessing of patient requests for MAID be done virtually, or do they need to be done in person?

The Criminal Code is silent on whether assessments of patient eligibility or witnessing of patient requests can be done virtually. That said, Health Canada has indicated that virtual tools can be used to support the MAID process during the pandemic.

The College acknowledges that virtual tools may be used to conduct patient eligibility assessments and witness requests for MAID in the same circumstances these tools are used for all health care: when physicians can satisfy all their legal and professional obligations. The use of virtual tools for health care, including MAID, is particularly relevant within the context of the pandemic and aligns with Health Canada’s guidance.

As with use of virtual tools in general, physicians must contemplate the appropriateness of using this modality on a case-by-case basis, ensuring they can meet their legal and professional obligations. In this context, conducting assessments of patient eligibility or witnessing patient requests for MAID virtually may introduce risks that need to be mitigated in order to ensure compliance with the Criminal Code (e.g., ensuring voluntariness) and physicians’ professional obligations. In addition to using their professional judgment, physicians might look to best practices or any guidelines that have been developed to support these practices. For example, the Canadian Association of MAID Assessors and Providers has collaborated with Dying with Dignity to develop resources which physicians may find helpful.

The College recognizes that virtual care has always played an important role in enabling access to MAID given the uneven distribution of MAID assessors and providers across the province, and similarly appreciates the increased value virtual tools offer to support access to care and mitigate the risks associated with providing care during a pandemic. Our focus is on ensuring that physicians comply with the requirements of the Criminal Code and that the procedural safeguards that have been put in place to protect patients are satisfied in all instances, whether done in-person or virtually.

I’m a patient and looking for assistance in accessing MAID or looking for more information, what can I do?

The provincial government has established a Care Coordination Service (CCS) for MAID to help clinicians connect patients with willing providers of MAID related services.

Patients may contact the CCS directly to receive information about end-of-life options in Ontario, including information on hospice care, other palliative care options in their communities, and MAID. Patients can also call the CCS to request to be connected to a physician or nurse practitioner who provides MAID services, such as eligibility assessments. The CCS can be reached toll free by calling 1-866-286-4023.

Effective Referrals: What Physicians Need to Know

The College recognizes that physicians have the right to limit the health services they provide for reasons of conscience or religion and so may choose not to be involved in assessing or providing MAID. In recognizing this right, the College does not require physicians to assess a patient’s eligibility for MAID or provide MAID in any circumstances.

When physicians limit the health services they provide for reasons of conscience or religion, the College requires that they provide patients with an ‘effective referral’.

What is an effective referral?

Physicians make an effective referral when they take positive action to ensure the patient is connected in a timely manner to a non-objecting, available, and accessible physicians, other-health-care professional, or agency that provides the service or connects the patient directly with a health-care professional who does.

The objective is to ensure access to care and respect for patient autonomy. An effective referral does not guarantee that a patient will receive a treatment or signal that the objecting physician endorses or supports the treatment. An effective referral also does not necessarily require that a referral in the formal clinical sense be made and does not require the physician to assess or determine whether the patient is a suitable candidate or eligible for the treatment to which the physician objects.

An effective referral involves taking the following steps:

  1. The physician takes positive action to connect a patient with another physician, healthcare professional, or agency. The physician can take these steps themselves or assign the task to someone else, so long as that person complies with the College’s expectations.
  2. The effective referral must be made to a non-objecting physician, healthcare professional, or agency that is accessible and available to the patient. The physician, healthcare professional, or agency must be accepting patients/open, must not share the same religious or conscience objection as the physician making the effective referral, and must be in a location that is reasonably accessible to the patient or accessible via telemedicine where appropriate.
  3. The effective referral must be made in a timely manner, so that the patient will not experience an adverse clinical outcome due to a delay in making the connection. A patient would be considered to suffer an adverse outcome due to a delay if, for example, the patient is no longer able to access care (e.g., for time sensitive matters such as emergency contraception, an abortion, or where a patient wishes to explore MAID), their clinical condition deteriorates, or their untreated pain or suffering is prolonged.

What are some examples of an effective referral?

The following are examples of the steps physicians can take to ensure their patient is connected in a timely and appropriate manner. The examples provided are not exhaustive and the steps needed to ensure a connection is made depend on the patient’s circumstances. Physicians will need to use their judgement, considering the patient’s particular circumstances, when determining how to meet this obligation.

The physician or designate contacts a non-objecting physician or non-objecting healthcare professional and arranges for the patient to be seen or transferred42.

The physician or designate connects the patient with an agency charged with facilitating referrals for the healthcare service, and arranges for the patient to be seen at that agency. For instance, in the MAID context, in appropriate circumstances an effective referral could include the physician or designate contacting Ontario’s Care Coordination Service (CCS). The CCS would then connect the patient with a willing provider of MAID-related services.

A practice group in a hospital, clinic or family practice model identifies patient queries or needs through a triage system. The patient is directly matched with a non-objecting physician in the practice group with whom the patient can explore all options in which they have expressed an interest.

A practice group in a hospital, clinic or family practice model identifies a point person who will facilitate referrals or who will provide the healthcare to the patient. The objecting physician or their designate connects the patient with that point person.

For more information regarding physicians’ right to freedom of conscience and religion and the basis for the College’s expectations, please see the College’s Advice to the Profession: Professional Obligations and Human Rights companion resource.

Endnotes

1. Carter v. Canada (Attorney General), 2015 SCC 5 [Carter].

2. Department of Justice, Government of Canada. (2021). Canada’s new medical assistance in dying (MAID) law. Available at: https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html

3. Department of Justice, Government of Canada. (2021). Canada’s new medical assistance in dying (MAID) law. Available at: https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html

4. Section 4 of Bill C-7 (assented to March 17, 2021): An Act to amend the Criminal Code (medical assistance in dying).

5. Library of Parliament. (2021). Research publications: Legislative Summary of Bill C-7: An Act to amend the Criminal Code (medical assistance in dying) Available at: https://lop.parl.ca/sites/PublicWebsite/default/en_CA/ResearchPublications/LegislativeSummaries/431C7E#a2-7

6. Section 241.2 (1) and (2) of the Criminal Code.

7. Section 241.2 (2.1) of the Criminal Code specifically excludes a mental illness as an illness, disease or disability that makes a person eligible for MAID. For clarity, a person suffering solely from a mental illness is not eligible for MAID but a person 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.

8. Section 241.2 (2.1) of the Criminal Code.

9. Section 2.1 of Bill C-7 (assented to March 17, 2021): An Act to amend the Criminal Code (medical assistance in dying).

10. Department of Justice, Government of Canada. (2021). Canada’s new medical assistance in dying (MAID) law. Available at: https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html

11. Department of Justice, Government of Canada. (2021). Canada’s new medical assistance in dying (MAID) law. Available at: https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html

12. Section 241.2 (1) (d) of the Criminal Code.

13. Section 241.2 (1) (e) of the Criminal Code.

14. Section 241.2 (3.3) of the Criminal Code states involuntary words, sounds or gestures made in response to contact do not constitute a demonstration of refusal or resistance.

15. 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.

16. Section 241.2 (3.2) – (3.4) of the Criminal Code.

17. Section 241.2 (3.5) of the Criminal Code.

18. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

19. Section 241.2 (3.4) of the Criminal Code.

20. Section 241.2 (3.2) (c) of the Criminal Code.

21. Section 241.2 (3.3) of the Criminal Code.

22. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

23. Government of Canada. (2020). Medical assistance in dying. Available at: https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html#grievous

24. Government of Canada. (2016). Medical assistance in dying. Glossary. Available at: https://www.justice.gc.ca/eng/cj-jp/ad-am/glos.html

25. Government of Canada. (2016). Medical assistance in dying. Glossary. Available at: https://www.justice.gc.ca/eng/cj-jp/ad-am/glos.html

26. Department of Justice. (2020). Legislative Background: Bill C-7: Government of Canada’s Legislative Response to the Superior Court of Quebec Truchon Decision. https://www.justice.gc.ca/eng/csj-sjc/pl/ad-am/c7/p4.html

27. A.B. v. Canada (Attorney General), 2017 ONSC 3759.

28. Section 241.2 (3.1) (e.1) of the Criminal Code.

29. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

30. Government of Canada. (2020). Charter Statement. Bill C-7: An Act to amend the Criminal Code (medical assistance in dying) (C-7). Available at: https://www.justice.gc.ca/eng/csj-sjc/pl/charter-charte/c7.html

31. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

32. Health Canada. (2021). Bill C-7 Medical Assistance in Dying (MAID) Implementation: Summary of Questions/Answers following FPT Briefing of new MAID law (March 26, 2021).

33. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

34. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

35. Section 241.2 (3.1) (g) of the Criminal Code.

36. Section 241.2 (3.1) (g) of the Criminal Code.

37. Section 241.2 (3.1) (h) of the Criminal Code.

38. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

39. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

40. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

41. Health Canada. (2021). Areas of Inquiry about Bill C-7 Implementation.

42. A transfer of care in this situation would be specific to the care to which the physician objects. A transfer is not equivalent to ending the physician-patient relationship. Physicians must not terminate the physician-patient relationship simply because the patient wishes to explore a care option to which the physician has a conscientious objection.