Approved by Council: June 2016
Reviewed and Updated: June 2016; July 2017; December 2018; April 2021; December 2023
Policies of the College of Physicians and Surgeons of Ontario ("CPSO”) set out expectations for the professional conduct of physicians practising in Ontario. Together with the Practice Guide and relevant legislation and case law, they will be used by CPSO and its Committees when considering physician practice or conduct.
Within policies, the terms ‘must’ and ‘advised’ are used to articulate CPSO’s expectations. When ‘advised’ is used, it indicates that physicians can use reasonable discretion when applying this expectation to practice.
Additional information, general advice, and/or best practices can be found in companion resources, such as Advice to the Profession documents.
Medical Assistance in Dying (MAID): Under the Criminal Code1, MAID refers to circumstances where a physician2 or nurse practitioner, at the patient’s request: (a) administers medications3 that cause the patient’s death; or (b) prescribes or provides medications for the patient to self-administer to cause their own death.
NOTE: The Criminal Code sets out the eligibility criteria for MAID. The Criminal Code currently excludes mental illness as an illness, disease, or disability that makes an individual eligible for MAID.4 This exclusion will remain in place until March 17, 2024, at which time it is expected to be repealed.
- Physicians must comply with:
- the legal requirements for MAID,5 including those pertaining to eligibility criteria, safeguards, and reporting (see CPSO’s Legal Requirements: MAID companion document); and
- the expectations set out in this policy and other relevant CPSO policies, such as the Human Rights in the Provision of Health Services policy, including the expectation regarding effective referrals for physicians who choose not to assess patients or provide MAID for reasons of conscience or religion.
- Before administering medications for MAID, physicians must have a contingency plan6 in place to address potential complications.
- Physicians must use their professional judgment when determining the appropriate medication protocol to achieve MAID and must ensure the goals of the protocol include controlling the patient’s pain and anxiety.
- Physicians must notify the dispensing pharmacist as early as possible that medications for MAID will be required to allow the pharmacist sufficient time to obtain and/or prepare the medications.
- Consistent with CPSO’s Medical Records Documentation policy, where applicable, physicians must include the following in the patient’s medical record:
- all requests for MAID, including a copy of any written request; 7, 8
- documentation demonstrating that the eligibility criteria and relevant procedural safeguards were met,9 including the analysis undertaken to determine if the patient’s natural death was reasonably foreseeable;10
- a copy of any written arrangement that waives the requirement for final express consent;11
- a copy of any report made to the Office of the Chief Coroner or Health Canada;
- the medication protocol used (i.e., drug(s) and dosage(s)); and
- the time and date of the patient’s death, if known.
1. R.S.C. 1985, c. C-46 (hereinafter, “Criminal Code”).
2. Postgraduate medical trainees can participate in the MAID process, but must only do so within the terms, conditions, and limitations of their certificate of registration.
3. While the Criminal Code uses the word “substance” when describing the MAID framework, CPSO uses the term “medications” in this policy.
4. 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.
5. 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.
6. A contingency plan may include, for example, a plan for failed vascular access or a back-up MAID kit in case the administration of medications fails.
7. This documentation requirement applies to all physicians who receive requests for MAID, including physicians who choose not to assess patients or provide MAID for reasons of conscience or religion.
8. The Ministry of Health has developed Clinician Aid A to assist patients who request MAID.
9. The Ministry of Health has developed Clinician Aid B for physicians who provide MAID and Clinician Aid C for physicians who are MAID assessors.
10. The Criminal Code framework has two “tracks” that contain different procedural safeguards depending on whether the patient’s natural death is reasonably foreseeable.
11. “Written arrangement” includes waivers of final consent and advance consent for self-administration. The Ministry of Health has developed Clinician Aids D-1 and D-2 for MAID providers and patients to use as templates for written arrangements.