Medical Assistance in Dying: Frequently Asked Questions for Physicians & Nurse Practitioners
NSHA’s comprehensive policy provides details about medical assistance in dying within NSHA. After reviewing the policy and these questions and answers, please contact the office 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 is medical assistance in dying?
The Criminal Code defines medical assistance in dying to mean:
(a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or
(b) 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.
Who can provide medical assistance in dying?
Any doctor or nurse practitioner is eligible to provide medical assistance in dying.
Who can receive medical assistance in dying?
The Criminal Code provisions state that a person may receive medical assistance in dying if they meet all of the following criteria:
- The person is eligible for health services funded by the federal government, or a province or territory (or during the applicable minimum period of residence or waiting period for eligibility);
- The person is at least 18 years of age and capable of making decisions with respect to his/her health;
- The person has a grievous and irremediable medical condition;
- The person has made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and
- The person gives informed consent to receive medical assistance in dying.
What is considered a “grievous and irremediable” medical condition?
The Criminal Code 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 – the Criminal Code sets the age at 18 for a person to request medical assistance in dying.
Requests set out in an advance directive– a physician or nurse practitioner cannot act on a request for medical assistance in dying that is set out in a personal directive or similar document.
Mental Illness or Physical Disability
A person with a mental illness or a physical disability may be eligible to receive medical assistance in dying. The person must meet all the criteria to be eligible for medical assistance in dying. Eligibility is assessed on an individual basis, looking at all of the relevant circumstances to determine if the person meets the criteria.
Will there be changes to eligibility?
It should be noted that the preamble to the Criminal Code provisions on medical assistance in dying provides:
“The Government of Canada has committed to develop non-legislative measures that would support the improvement of a full range of options for end-of-life care, respect the personal convictions of health care providers and explore other situations — each having unique implications — in which a person may seek access to medical assistance in dying, namely situations giving rise to requests by mature minors, advance requests and requests where mental illness is the sole underlying medical condition.”
What is NSHA’s role in 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 do I do 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 concerns about their role or require guidance they should contact the CPSNS. Where a physician requires legal advice regarding their role they are advised to contact the Canadian Medical Protective Association (CMPA).
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 my patients with medical assistance in dying?
No. You are not obligated to provide medical assistance in dying to your patient if doing so would violate your moral conscience. Section 241.2 (9) of the Criminal Code 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.
You do, however, have an obligation to provide an effective transfer of care for the patient.
You may direct the request to the Medical Affairs Advisor by phoning 902-491-5892.
Can I decline to provide medical assistance in dying for reasons other than moral conscience?
Physicians may 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.
Nurse Practitioners are guided by the CRNNS Code of Ethics.
If you decline to provide or participate in request for medical assistance in dying, you do, however, have an obligation to provide an effective transfer of care for the patient.
You can also call the office of NSHA’s Vice President of Medicine at 902-491-5892 for assistance.
As a doctor or nurse practitioner, can I conduct one of the assessments for medical assistance in dying and also provide the service?
Yes. For a patient to undergo medical assistance in dying, there must be two assessments completed by two different doctors and/or nurse practitioners. However, one of those professionals can also be the one to administer medical assistance in dying, if that is the wish of both the patient and the provider.
What other options are there to relieve the suffering of my patients and/or provide end-of-life medical care?
It’s important that you talk to your patient about their options. These options could include medical treatments, a referral to a palliative care specialist/team, psychological support, spiritual care and/or medical assistance in dying.
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 am interested in providing medical assistance in dying. Who do I contact to express interest or learn more?
It is important that Nova Scotians who choose and qualify for MAiD are able to access it in a timely way and close to home. To consistently achieve this standard, we are seeking more physicians and NPs who are willing and able to provide this service.
To express interest or to learn more, please contact the Medical Affairs Advisor at 902-491-5892.
If I do provide medical assistance in dying, must I do so through 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 are intended to apply to the NSHA care setting or program; but may also help inform a physician or nurse practitioner in a non-NSHA community practice.
Have medication protocols been developed?
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 NSHA includes a notice to pharmacist that the order is for medical assistance in dying. The notice must be completed as part of the order.
If I ask other health care providers to be involved in medical assistance in dying in any way, do I need to disclose why I am asking for their support?
Yes. If you are asking another health care provider to support medical assistance in dying in any way, it’s important that you clearly disclose this information. It is within that health care provider’s right not to support medical assistance in dying, either for reason of conscience or because they do not feel they have the skills or training to do so.
Will I be responsible for finding an appropriate location for medical assistance in dying to take place?
Some patients may request to die at home, while others may choose another location. You can find more information about patient location and responsibility for registration in section 6 of the Medical Assistance in Dying policy.
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 or nurse practitioner to always be present at the time of administration of the medication. Availability and appropriate intermittent visual monitoring of the patient until death is also required.
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?
Yes. As of November 1, 2018, the Regulations for the Monitoring of Medical Assistance in Dying (the Regulations) came into effect. The Regulations require physicians, nurse practitioners, and pharmacists to provide information related to requests for, and the provision of, medical assistance in dying (MAID).
What supports will be available for me if/when I provide medical assistance in dying?
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