Medical Assistance in Dying: Frequently Asked Questions for Physicians & Nurse Practitioners
NSHA’s comprehensive policy is under development. In the interim, please contact the office of the Medical Affairs Advisor at 902-491-5892 if you have questions or if you receive a specific request for Medical Assistance in Dying. The voicemail box will be checked regularly during the hours of 8:30 a.m. to 4:30 p.m., Monday to Friday, and we are committed to getting back to you as soon as possible. Please leave your name, number and a brief explanation of the information you are seeking so we can best address your questions and concerns.
What do we mean when we use the terms “physician assisted death” and “medical assistance in dying”?
Before April 2016, you will have primarily heard about references to “physician assisted death.” This language arose because the Supreme Court of Canada, in the Carter decision, considered the role of physicians in “physician assisted dying, physician assisted death and medical assistance in dying” a situation where a physician either provides (commonly referred to as “physician assisted suicide”) or administers (sometimes referred to as “voluntary euthanasia”) medication that intentionally brings about the patient’s death, at the request of the patient. Since April, the language has changed, based primarily on the language of the federal legislation (Bill C-14), to refer to Medical Assistance in Dying.
What is the current status of the laws related to medical assistance in dying?
In February 2015, the Supreme Court of Canada ruled that the criminal laws prohibiting physician assistance in dying limited the rights of Canadians to life, liberty and security of the person (s. 7 of the Charter) and issued a declaration that sections 241(b) and 14 of the Criminal Code are void:
“insofar as they prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life; and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition”
The effect of declaration was suspended for 12 months to allow the federal government to consider what, if any, legislation would be required. On January 15, 2016, the Supreme Court of Canada extended the 12-month period to June 6, 2016 to allow time to develop legislation.
On June 17, Bill C-14 received royal assent, meaning the bill is now legislation. The latest available version of the Bill can be accessed here.
How is medical assistance in dying defined?
Legislation defines medical assistance in dying in the following ways:
Voluntary euthanasia - the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes death; or
Assisted suicide - the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.
What are the eligibility criteria for receiving medical assistance in dying?
The law states that a person may receive medical assistance in dying only if they meet the following criteria:
(a) they are eligible — or, but for any applicable minimum period of residence or
waiting period, would be eligible — for health services funded by a government in
(b) they are at least 18 years of age and capable of making decisions with respect to
(c) they have a grievous and irremediable medical condition;
(d) they have made a voluntary request for medical assistance in dying that, in
particular, was not made as a result of external pressure; and
(e) they give informed consent to receive medical assistance in dying.
What is considered a “grievous and irremediable medical condition”?
The law states that a person has a grievous and irremediable medical condition if:
(a) they have a serious and incurable illness, disease or disability;
(b) they are in an advanced state of irreversible decline in capability;
(c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and
(d) their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.
What is excluded from the legislation?
At this time, the following are excluded:
- requests by mature minors
- advance requests
- where mental illness is the sole underlying medical condition
The Federal Government has committed to further study as it relates to these exclusions.
What is NSHA’s role in providing medical assistance in dying?
NSHA is committed to providing decision-making support to patients, families and health care providers. In keeping with the medical assistance in dying legislation and professional standards of practice for health care professionals, NSHA will:
- Provide information about the procedure
- Facilitate access to the procedure
- Provide support to physicians, nurse practitioners and other involved staff as required
- Provide education to physicians, nurse practitioners, staff, patients and public
What steps do I follow if I receive a request for medical assistance in dying?
Physicians or nurse practitioners receiving a request from a patient for information about, or access to, medical assistance in dying should undertake their usual exploration with the patient about what is behind the request, sensitively and compassionately addressing the patient’s needs and concerns.
The College of Physicians & Surgeons of Nova Scotia (CPSNS) has provided a Professional Standard Regarding Medical Assistance in Dying. It is important for you to know your responsibilities under this standard – whether you plan to provide the service or not. In any case where a physician has doubt about the legalities of any role they may play, or need for specific legal guidance, they are advised to contact the Canadian Medical Protective Association (CMPA) at 1-800-267-6522.
The College of Registered Nurses Nova Scotia (CRNNS) has developed guidelines for Medical Assistance in Dying for nurse practitioners. It is important for you to know what is in the guidelines – whether you plan to provide the service or not.
Am I obligated to provide medical assistance in dying to my patients?
You are not obligated to provide medical assistance in dying to your patient if doing so would violate your moral conscience. Since the passing of Bill C-14, Section 241.2 (9) of the Criminal Code now reads “Nothing in this section compels an individual to provide or assist in providing medical assistance in dying.”
Objection for reason of conscience is further addressed in the CPSNS Professional Standard Regarding Medical Assistance in Dying and in the CRNNS Code of Ethics. Your obligations and processes to address issues as they arise in your practice are covered in the CPSNS standard and the CRNNS Medical Assistance in Dying: A Practice Guide for Nurse Practitioners and – from an NSHA practice perspective – can be directed to the office of the NSHA VP Medicine’s office by phoning 902-491-5892.
Can I decline to provide medical assistance in dying to my patients for reasons other than moral conscience?
Yes, physicians may also decline to provide medical assistance in dying for other reasons, including:
- when a physician considers themselves not to be properly skilled or trained to safely provide the service, or
- when a physician determines a patient does not fit the criteria for access to medical assistance in dying.
The College of Physicians & Surgeons of Nova Scotia Professional Standard Regarding Medical Assistance in Dying provides information as to the obligations of physicians in this situation. Conscientious objection is guided for Nurse Practitioners through the CRNNS Code of Ethics.
You can also call the office of NSHA’s Vice President of Medicine at 902-491-5892.
If I agree to provide medical assistance in dying, must I do so within NSHA?
No. Medical assistance in dying may be provided in non-NSHA community settings as well as within NSHA facilities. The College of Physicians & Surgeons of Nova Scotia Professional Standard Regarding Medical Assistance in Dying will be the primary reference point for physician practice in community settings. Nurse Practitioners can provide Medical Assistance in Dying in settings that are consistent with their applicable scope and standards of practice. The protocols and supporting materials developed by NSHA and accessed by calling 902-491-5892 are intended to apply to the NSHA care setting or program but may also help inform non-NSHA community practice.
What are my responsibilities upon becoming aware of the intent of a patient to seek medical assistance in dying?
Upon becoming aware that a patient is intending to seek medical assistance in dying in an NSHA facility or using NSHA resources, notify the office Dr. Lynne Harrigan, VP Medicine, NSHA, at 902-491-5892. It is also recommended that you contact Dr. Harrigan in relation to requests related to non-NSHA community-based settings. Dr. Harrigan’s office will assist the physician or nurse practitioner to put the request into action, including providing access, where necessary, to the relevant other providers, drugs and protocols that may be required.
Does NSHA have a policy to govern medical assistance in dying?
NSHA does have a draft policy. However, because the legislation reached royal assent only recently, the processes outlined in this document (specifically contact by calling 902-491- 5892) will apply until this policy -- including consultation with stakeholders -- is complete.
Have medication protocols been developed?
We have prepared for use in Nova Scotia Health Authority facilities and programs, a pre-printed order for intravenous therapy (IV). You can access this protocol by calling 902-491-5892 in instances where medical assistance in dying is proceeding. Similar to other provinces, we are working on a protocol for medical assistance in dying through oral administration. Consideration is also underway as to appropriate oral medication protocols. We will keep you advised as these are finalized.
Do I need to inform the pharmacist what the pre-printed order is for?
According to section 241.2 (8) of the legislation, the “medical practitioner or nurse practitioner who, in providing medical assistance in dying, prescribes or obtains a substance for that purpose must, before any pharmacist dispenses the substance, inform the pharmacist that the substance is intended for that purpose.” The pre-printed order prepared by Nova Scotia Health Authority includes a notice to pharmacist that the order is for medical assistance in dying. The notice must be completed as part of the order.
Will I be responsible to find an appropriate location for the medical assistance in dying service to take place?
Some patients may request to die at home, while others may choose another location. For a variety of reasons, it will not be possible to provide medical assistance in dying at all health care sites in the province. In the period before there is an NSHA policy to help with these matters, and should the request relate to a location within an NSHA facility, the office of Dr. Lynne Harrigan, VP Medicine for NSHA, will provide the necessary assistance. Please call 902-491-5892.
Do I need to be present while the patient self-administers the medication that will intentionally bring about their death?
Within NSHA facilities, the requirement is for a physician to always be present at the time of either self-ingestion or physician administration. Availability and appropriate intermittent visual monitoring of the patient until death is also required.
We have also received advice that it is highly recommended that physicians be present with the patient.
In many cases the patient and family may feel more comfortable knowing the physician will be there to comfort, monitor the event, and explain what is happening if there are questions. In addition, it allows for corrective actions to be taken should there be issues that arise with the patient’s self-ingestion of the drugs in the protocol. If not present with the patient, it is most prudent that the physician be readily available in order to manage any complications, support the patient and family and declare death.
Do I need to fill in any paperwork?
NSHA, with guidance from the CPSNS Professional Standard Regarding Medical Assistance in Dying, provides physicians and NPs with a request and consent form, and documentation and procedure checklist to help in documenting the decision-making process and required consent for medically assisted dying.
Are there any reporting requirements?
We are waiting for clarity in relation to reporting requirements and will provide information as we receive it.
Does NSHA have any tools and resources available for physicians and nurse practitioners?
Additional information and materials will be provided through the NSHA website (http://www.nshealth.ca/medical-assistance-dying) in the near future. In the interim, you can access assistance by calling 902-491-5892.
Who do I contact if I want to provide medical assistance in dying?
Please contact Dr. Lynne Harrigan, VP Medicine, at 902-491-5892.
What other options are there to alleviate the suffering of my patient(s) and/or provide end-of-life medical care?
Palliative Care is different than medical assistance in dying.
A member of the health care team and a patient’s physician can and will, with their patient’s consent and involvement, take steps to connect the patient with palliative care services. It is important that when a patient has been given a diagnosis of a life-limiting illness with a serious or grave prognosis, that they have the option for palliative care.
Palliative Care is defined by the World Health Organization as an approach that improves the quality of life of patients and their families facing challenges associated with life-threatening illness through the prevention and relief of suffering by means of early identification and impeccable assessment and treatment of pain and other physical, psychological and spiritual problems.
Palliative Care and other practitioners will continue to work closely with patients and families to understand and manage their disease and symptoms. Palliative care seeks to:
- provide relief from pain and other distressing symptoms
- help individuals manage symptoms, address physical, emotional and spiritual concerns
- support families
- enhance quality of life and help patients live as actively as possible
- prepare individuals for death, and
- offer bereavement support to loved ones
Palliative care involves a team made up of various health providers. This type of care can support people in their homes, at hospices, in supportive living environments and in hospitals. We understand that the Provinces and Territories will be working with the Federal Government to improve palliative care services for all Canadians.
I’m not sure how I will feel about being involved with assisted dying. What supports will be available for me?
Medical assistance in dying can be a very challenging care scenario for professionals. It is important that we support each other and seek out counsel and support from our managers, professional colleges and co-workers.
Employee and Families Assistance Program (EFAP) is a voluntary, confidential, short-term counselling, advisory and information service for employees of NSHA and eligible family members.
- Metro Halifax: 902-422-2273
- Toll Free: 1-800-461-5558