This section includes information that we hope will be useful to our members. Materials posted prior to June 6th are shown on a separate page.

MAiD Pre Legalization

CSPCP Response to Article in CMAJ

(April 2021) At the request of members of the CSPCP, the Board responded to an article in the CMAJ entitled “A unique milestone”. View the article and response here: https://www.cmaj.ca/content/193/10/E345

CSPCP input to CPSO consultations

(April 2021) The College of Physicians and Surgeons of Ontario (CPSO) is conducting public consultations on several policies including Medical Assistance in Dying, Planning for and Providing Quality End-of-Life Care, and Professional Obligations & Human Rights. The CSPCP Board prepared the attached brief and submitted it to CPSO on March 31st. As promised in the e brief, we are sharing it with CSPCP members.

The CPSO invites all Canadians to participate. Since their policies could be precedent setting for other provincial colleges, we encourage you to take part. You are welcome to reference content from our brief, if you wish.

Links to the three consultations can be accessed from the Consultations page of the CPSO web site.

The consultation deadline is April 30th, 2021.

Bill C-7 Update

(March 2021). Bill C-7, An Act to amend the Criminal Code (medical assistance in dying) became law on March 17, 2021. Several of the amendments may have a significant effect on the practice of palliative care.

Key changes are summarized below.

1. Removal of reasonably foreseeable death criterion. The law no longer requires a person’s natural death to be reasonably foreseeable as an eligibility criterion for MAID (Medical assistance in dying).
2. Removal of the 10-day reflection period. For those whose natural death is reasonably foreseeable, the 10-day reflection period is no longer required between the written request for MAiD and the procedure.
3. Waiver of final consent for MAiD. For those whose natural death is reasonably foreseeable, the requirement for consent at the time of MAiD procedure has been waived.
4. Change in requirement for witness signing a request for MAiD. Only one instead of two independent witnesses are required to verify written consent for MAiD and that witness may now be a paid health care worker.
5. New safeguards for those without a reasonably foreseeable natural death. There must be 90 days between the first assessment and MAiD procedure, which can be shortened if an individual is at risk of losing capacity to consent. The individual must have been seen by a medical professional with expertise in their underlying condition.
6. Sunset clause on the exclusion of mental illness as a sole underlying diagnosis in 24 months. Individuals with mental illness as a sole underlying diagnosis will be eligible to qualify for MAiD starting on March 17, 2023.

Links for more details:

Department of Justice Web page “Canada’s new medical assistance in dying (MAID) law”.
The Bill and its amendment: https://parl.ca/DocumentViewer/en/43-2/bill/C-7/royal-assent

CSPCP’s Advocacy:

The CSPCP presented to the responsible committees studying the Bill for the House of Commons and the Senate. Our written briefs and oral presentations are posted here: https://archive.cspcp.ca/cspcp-input-to-justice-committee-re-bill-c-7/. We also signed onto the attached Open Letter “Bill C-7 is not the answer”, prepared by the Vulnerable Persons Standard. While we do not support some of the language used in the letter, especially as it relates to Long Term Care, we felt it important to lend our support because of the implications this Bill may have on the practice of palliative care.

CSPCP Input Re Bill C-7

(November 2020). The Parliament of Canada is currently reviewing Bill C-7, An Act to amend the Criminal Code (medical assistance in dying). Parts of the proposed Bill have significant implications for palliative care and despite the very tight timelines involved, the CSPCP has been actively working to provide input accordingly.

The first step in the parliamentary process was review by the House of Commons Standing Committee on Justice and Human Rights. The CSPCP submitted a written brief (English; French). We were subsequently invited to give a 5-minute presentation to the Committee and to participate in a question period. CSPCP President Dr. Anne Boyle and CSPCP Member Dr. Harvey Chochinov represented the CSPCP. They focused on the evidence in the literature that addressed the Government’s proposed changes to the law. (View proceedings here. CSPCP presented at 12:25:45)

The second step was review by the Senate Standing Committee on Legal and Constitutional Affairs. The CSPCP submitted a written brief (same as the one above). CSPCP Past-President Dr. Leonie Herx gave a 5-minute presentation and participated in the question period that followed. Dr. Herx summarized the CSPCP’s concerns and recommendations for safeguards to minimize harm. View her presentation here. (Full proceedings here: SenVu (parl.gc.ca)).

Updated Key Messages from CSPCP re Palliative Care and Medical Assistance in Dying (MAiD) – May 2019

CSPCP Key Messages PC and MAiD May 2019 FINAL

Health Canada’s First Annual Report on MAID in Canada (2019)

Released by Health Canada on July 24, 2020

English: https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html
French: https://www.canada.ca/fr/sante-canada/services/aide-medicale-mourir-rapport-annuel-2019.html

If you have questions about the report, please contact the End-of-Life Care Unit in Health Canada: hc.eolc-sfv.sc@canada.ca

4th Interim report on MAiD from Health Canada

This report was issued in May 2019.

To view English click here
To view French click here

3rd Interim report on MAiD from Health Canada (June 2018)

Read More

CSPCP input to proposed regulations for monitoring of MAiD (Feb 2018)

Health Canada invited submissions regarding proposed regulations for monitoring of MAiD (viewable here: http://www.gazette.gc.ca/rp-pr/p1/2017/2017-12-16/html/reg6-eng.html)

The CSPCP submitted two strong recommendations:
1. To record the nature of the grievous and irremediable suffering
2. To measure, monitor, and reporting on the availability of alternatives such as palliative care, social services, and respite.

View the CSPCP submission here

CSPCP Members Survey about MAiD – Results (Feb 2018)

In October 2017, the Canadian Society of Palliative Care Physicians (CSPCP) conducted a survey of its members regarding Medical Assistance in Dying (MAiD). The purpose of the survey was to help the CSPCP Board to accurately represent members’ views and to guide future actions.

To view the results, click here

Can MAiD harm rural and remote palliative care in Canada?

Excellent article written by CSPCP Member Dr. Andrew Collins, in Canadian Family Physician. March 2017.

http://www.cfp.ca/content/63/3/186.full

Reasons to keep MAiD out of palliative care units and hospice facilities

The letter below was written by CSPCP Board member Pippa Hawley to the Board of Fraser Health in BC. Fraser Health is considering whether to mandate that all palliative care units and hospice facilities in the region will have to provide Medical Assistance in Dying (MAiD) within their units or facilities. Dr. Hawley’s letter provides two compelling arguments against this.

Read More

CSPCP Resource Document: Sample messaging for palliative care programs that choose not to offer hastened death (i.e., medical assistance in dying – “MAID”) – June 2016

The purpose of this document is to provide sample messaging that palliative care programs can share with their program staff about how to respond to patients on inquiries related to the above. The messages may not reflect the views of all palliative care programs but are they intended as a starting point that can be adapted for your own use.

Link to the attached document.

SAMPLE LETTERS FROM PALLIATIVE CARE PROGRAMS

PEI Read More

New Brunswick Read More

Alberta – specialized acute-care palliative unit: Read More

We welcome additional examples which we will consider for posting. Send to: office@cspcp.ca

PROVINCIAL POLICIES RE MAID

Summary from the Canadian Hospice Palliative Care Association: http://www.chpca.net/13144.aspx

All 10 Provincial Medical regulating bodies and one territorial body now have MAID guidelines in place and are detailed below, with source link included:

British Columbia

• Two independent physicians must agree a patient meets the criteria set out by the Supreme Court.
• The patient must be eligible for publicly funded health care, able to give free and informed consent throughout the process.
• No advance requests.
• The patient must consistently express a desire for MAID over a “reasonable period of time” — 15 days in most cases but dependent on each patient’s condition and circumstances.
• Formal written request required, signed by the patient and one witness who is not related, entitled to a portion of the patient’s estate, or involved in treatment.
• Physicians may refuse to provide MAID but they must provide “an effective transfer of care.”

Source

Alberta

• Two doctors must independently agree the patient meets all criteria set out by the Supreme Court.
• Patient must be “competent throughout the process.” No advance requests.
• The college notes that legal precedent recognizes mature minors as adults in their ability to consent but recommends “a careful and conservative approach” to mature minors.
• Doctors may refuse to provide MAID but have “an obligation” to provide patients with timely referrals to doctors who will perform the service.
• Requests must be in writing, signed by the patient and two witnesses, at least one of whom cannot be related to the patient, entitled to any portion of the patient’s estate or involved in treatment of the patient.
• Where capacity is unclear or where a person is suffering from depression or other mental illness, a psychiatric or psychological consult is required.
• A period of reflection of 14 days from initial request to final consent is recommended.

Source

Saskatchewan

• Two doctors must agree the patient meets the criteria set out by the Supreme Court. Adult is defined as at least 18 years of age.
• Patient must repeatedly give free, informed consent throughout the process, up to the time of dying.
• No advance requests.
• Attending doctor must ensure the patient has consistently expressed a desire for MAID “over a reasonable period of time,” the length of which is dependent on the patient’s condition.
• Physicians may refuse to provide MAID but must arrange “timely access” to another doctor or resource.
• Patient must fill out a prescribed form confirming informed consent to receive MAID.

Source

Manitoba

• At least two physicians must independently agree the patient meets the Supreme Court’s criteria. Adult is defined as 18 years of age.
• Independent psychiatric assessment required where a patient does not have a terminal illness (prognosis of less than six months) or is not suffering from a “catastrophic and irreversible physical injury” or intractable physical pain or an advanced state of irreversible, significantly impaired function or imminent decline to that state. The assessment must rule out a treatable psychiatric disorder that is impairing patient’s ability to tolerate suffering or assess treatment options.
• Each doctor must meet at least once with the patient to ensure that the patient is competent, fully informed and that the decision to terminate life “a clear and settled” choice, without undue coercion or influence.
• No advance requests.
• A waiting period of at least seven days, except for those whose death is imminent.
• Written consent, signed by the patient.
• Physicians may refuse to provide MAID or to refer a patient to another doctor but must provide “timely access to a resource” that will provide the necessary information.

Source

Ontario

• Two doctors must agree the patient meets criteria set out by the Supreme Court. College recommends that only patients in Canada, covered by publicly funded health care, be eligible. It notes that the court did not define the term “adult.”
• No advance requests.
• Physicians may refuse to provide MAID but must make an “effective referral” of the patient to an available, accessible physician or agency that will.
• An unspecified waiting period is required, length depending on the patient’s condition.
• A formal written request is required, signed by the patient, the attending physician and an independent witness.

Source

Quebec*

• A patient must be covered by provincial health care, be of “full age” and capable of giving consent, be at the end of life, suffering from a serious and incurable illness, in an advanced state of irreversible decline and experiencing constant and unbearable physical or psychological suffering which can’t be relieved in a manner acceptable to the patient.
• Two doctors must agree patient meets the criteria for MAID.
• Request must be made in writing.
• No advance requests.
• Physicians may refuse to provide MAID but must immediately notify authorities who will take steps to find another doctor.

*Note: The Quebec provincial law on assisted dying was drafted before the Supreme Court ruling

New Brunswick

• Patient must meet criteria set out by the Supreme Court, which is further defined as suffering from a grievous illness for which there is no cure and which will eventually cause death.
• The college notes that MAID could theoretically be available to any patient who can legally consent. In N.B., the age of legal consent is 16.
• Patients with progressive illnesses who are also suffering from “intractable depression” are not automatically ineligible but doctors should proceed with “extraordinary caution” in such cases.
• Physicians may refuse to provide MAID or to make a direct referral but must provide patients with information on accessing MAID.
• Doctor must be satisfied that patient’s wish is “persistent, consistent and unshakable,” documenting patient’s request for MAID at least twice, two weeks apart, and again just before administering MAID.
• No advance requests.
• Administering physician should obtain additional medical opinions as deemed appropriate to confirm prognosis, alternative options, and patient’s capacity to make a free, fully informed choice.

Source

Nova Scotia

• Two doctors must agree a patient meets criteria set out by the Supreme Court. Adult is defined as at least 19 years of age.
• No advance requests.
• Physicians may refuse to provide MAID for reasons of conscience but college recommends they provide “an effective referral” to another doctor.

Source

Newfoundland and Labrador

• Two doctors must agree a patient meets the criteria set out by the Supreme Court. Adult is defined as at least 19 years of age.
• No advance requests.
• Written request required, signed by patient and one independent witness.
• Physicians may refuse to provide MAID but should provide “timely access” to another doctor or information resource that is available and accessible to the patient.

Source

Prince Edward Island

• Two doctors must agree the patient meets the criteria set out by the Supreme Court. Must have a current provincial health care card and the capacity to freely and repeatedly consent throughout the process, up to the time of dying. Adult is defined as at least 18 years of age.
• Request must be in writing, witnessed by two independent persons with no connection to the patient.
• Doctor must ensure patient has repeatedly expressed a desire for MAID “over a reasonable period of time,” which may vary depending on patient’s condition.
• No advance requests.
• Physicians may refuse to provide MAID but must provide, or arrange to be provided, the patient’s chart to other physicians.

Source

Yukon

• Two doctors must agree the patient meets criteria set out by the Supreme Court. The Yukon Medical Council notes that it is uncertain if MAID could be legally available to minors.
• Patient must maintain decision-making capacity throughout the process, up to time of dying.
• No advance requests.
• Written request for MAID required, signed by patient and two witnesses, one of whom is not related, entitled to any benefit from the patient’s estate or involved in the provision of treatment.
• If a physician believes the patient suffers from psychiatric or psychological disorder or depression that could impair capacity to make an informed choice, the patient must be referred for assessment.
• A waiting period of 14 days is recommended.
• Physicians may refuse to provide MAID but must arrange “timely access” to another doctor or resource.

Source

CMA COURSES RE: EOL CARE AND MEDICAL ASSISTANCE IN DYING

The CMA offers on-line and in-person courses regarding EOL Care and MAiD.

https://www.cma.ca/en/pages/education-eol-care-medical-assistance-dying.aspx

DECISION-MAKING FRAMEWORK FOR PALLIATIVE CARE PATIENT ACCESS TO HASTENED-DEATH

Shared by Dr. Monica Branigan (May 2016) Read More

MESSAGE FROM CMPA: JUNE 6th

View an update about the current medico-legal situation regarding Hastened Death.
Click Here