Skip to main content

Introduction

In accordance with the Criminal Code and other legislation, the BCCNM standards of practice, and provincial and organizational policies and procedures, nurse practitioners may provide a client with medical assistance in dying (MAiD).

The purposeful and intended outcome of medical assistance in dying is to assist an eligible client explicitly requesting assistance in dying to end their life in a respectful, culturally appropriate, safe, ethical, legal and competent manner. 

Nurse practitioners contemplating participation in medical assistance in dying need to confer with their employer about their employer’s requirements.

Nurse practitioners may contact practice support at BCCNM to discuss professional and ethical obligations. Legal advice is also available for nurse practitioners from the Canadian Nurses Protective Society.

Overview of Medical Assistance in Dying

Only two forms of medical assistance in dying are permitted under the Criminal Code:

  • the administering by a medical practitioner or nurse practitioner of a substance to a client at their request that causes their death
  • the prescribing or providing by a medical practitioner or a nurse practitioner of a substance to a client at their request, for their self-administration that in doing so causes their own death.

The Criminal Code requires that a client requesting medical assistance in dying is informed of the means that are available to relieve their suffering, including palliative care. This supports the client requesting medical assistance in dying to gather information needed to make an informed decision about their health care options.
Health professionals are permitted to provide information about medical assistance in dying. However, directing, counselling or recommending a client to end their life remains an offence under the Criminal Code.

As of March 17, 2021 the MAiD eligibility criteria and safeguards in the Criminal Code were updated. Updates include that clients with a grievous and irremediable medical condit ion no longer require their death to be reasonably foreseeable to be eligible receive MAiD; however, additional safeguards have been added to the Criminal Code which must be satisfied before a MAiD can be provided to such a client. In certain circumstances, clients whose death is reasonably foreseeable can also now waive the requirement for final consent to receive MAiD if they lose the capacity to consent before MAiD is provided to them.

Definitions

The following terms are used in this standard:

  • Assessor: A nurse practitioner or medical practitioner who is responsible for completing an eligibility assessment of the client.
  • Assessor-Prescriber: A nurse practitioner or medical practitioner who is responsible for completing both an eligibility assessment and providing medical assistance in dying by prescribing and (when applicable) administering the substance to be used in MAiD. This role may be referred to by other regulatory colleges as the “prescribing nurse practitioner”.

Nurse Practitioner Role in Medical Assistance in Dying

The nurse practitioner role in medical assistance in dying under the Criminal Code can encompass:

  • determining the eligibility of the client requesting medical assistance in dying based on the eligibility criteria established in the Criminal Code
  • providing MAiD by administering the medical assistance in dying substances to a client, at their request, that causes their death
  • providing MAiD by prescribing and/or providing the medical assistance in dying substances to a client, at their request, so that they may self-administer the substance and in doing so cause their own death
  • aiding in the provision of medical assistance in dying by a medical practitioner or another nurse practitioner1

Transfer of Request for Care

Any nurse practitioner receiving a written request for MAiD who transfers the care of the client for any reason must complete the provincial form to report details about this transfer of care. See the BC Ministry of Health Medical Assistance in Dying website for more details.

Conscientious Objection

A nurse practitioner may have beliefs and values that differ from those of a client. Nothing in the Criminal Code compels nurse practitioners to aid in the provision of medical assistance in dying, determine eligibility for, or provide medical assistance in dying. The Duty to Provide Care practice standard provides guidance on how a nurse practitioner can address conscientious objection.

The standard requires nurse practitioners with a conscientious objection to take all reasonable steps to ensure that the quality and continuity of care for clients seeking or receiving medical assistance in dying are not compromised. This includes ensuring a safe transfer of care to an alternate provider that is timely, continuous, respectful and addresses the unique needs of a client.

The Duty to Provide Care practice standard also requires nurse practitioners with a conscientious objection to notify their organization well before the client is to receive medical assistance in dying. If medical assistance in dying is unexpectedly proposed or requested and no arrangement is in place for alternative providers, that practice standard further requires nurse practitioners to inform those most directly involved in the care of the client of their conscientious objection. 

Eligibility Requirements for Medical Assistance in Dying (Criminal Code Section 241.2(1) and (2))2

As of March 17, 2021, clients who wish to receive MAiD must satisfy all of the following eligibility criteria:

  • be 18 years of age or older and have decision-making capacity
  • be eligible for publicly funded health care services
  • make a voluntary request that is not the result of external pressure
  • give informed consent to receive MAiD, meaning that the client has consented to receiving MAiD after they have received all information needed to make this decision, including information about the means available to relieve their suffering (including palliative care)
  • have a serious and incurable illness, disease or disability (excluding a mental illness)
  • be in an advanced state of irreversible decline in capability
  • have enduring and intolerable physical or psychological suffering that is intolerable to them and cannot be alleviated under conditions the client considers acceptable

Procedural Safeguards (Criminal Code Section 242.1(3))3

The following procedural safeguards must be satisfied before MAiD is provided to any client:

  • the request for MAiD must be made in writing; a written request must be signed by an independent witness, and it must be made after the client is informed that they have a “grievous and irremediable medical condition”
  • two independent nurse practitioners or medical practitioners, including the assessor-prescriber and a second independent assessor, must assess the client and confirm their opinion that the client meets all of the eligibility criteria listed above
  • the client must be informed that they can withdraw their request at any time, in any manner
  • if the client has difficulty communicating, all necessary measures must be taken to provide a reliable means for the client to understand the information provided to them and communicate their decision
  • the client must be given an opportunity to withdraw consent and must expressly confirm their consent immediately before receiving MAiD; however, this “final consent” requirement can be waived in certain circumstances for a client whose natural death is reasonably foreseeable

Additional Procedural Safeguards for Clients Whose Natural Death is not Reasonably Foreseeable ((Criminal Code s. 241.2(3.1))4

In addition to all of the above safeguards, the following further procedural safeguards must also be satisfied before MAiD is provided to any client whose natural death is not reasonably foreseeable:

  • if neither the assessor-prescriber nor the second independent assessor who has assessed the client has expertise in the medical condition that is causing the client’s suffering, they must consult with another nurse practitioner or medical practitioner who has such expertise
  • the client must be informed of available and appropriate means to relieve their suffering, including counselling services, mental health and disability support services, community services and palliative care, and must be offered consultations with professionals who provide those services
  • the client, the assessor-prescriber, and the second independent assessor who has assessed the client must all have discussed reasonable and available means to relieve the client’s suffering, and they must all agree that the client has seriously considered those means
  • there must be at least 90 days between the time that the client is first assessed as meeting the eligibility criteria listed above and the time that MAiD is provided to the client; however, this period can be shortened (as the assessor-prescriber considers appropriate in the circumstances) if both the assessor-prescriber and the second independent assessor have completed their assessments of the client, and if they both agree that the client is about to lose the capacity to make health care decisions.

Independence of Assessor-Prescriber and Second Assessor (Criminal Code s. 241.2(6))

To act as the client’s assessor-prescriber or as the second independent assessor who assesses the client, a nurse practitioner or medical practitioner must meet all of the following requirements:

  • neither the assessor-prescriber nor the second assessor may be a mentor to the other or responsible for supervising their work
  • they must not know or believe that they are a beneficiary under the client’s will, or that they will benefit in any other way from the client’s death
  • they must not know or believe that they are connected to the client or the other practitioner in another other way that would affect their objectivity

Witnessing Requests for Medical Assistance in Dying (Criminal Code s. 241.2(5) and (5.1))5

The role of the independent witness is to provide confirmation of the client’s signing and dating of their request for MAiD, and that the client understands what they are signing.

An independent witness must be at least 18 years of age and must understand what it means to request MAiD.

An independent witness can be a paid professional personal or health care worker who does not act as the client’s assessor-prescriber or the second independent assessor.

To be considered independent means that the witness cannot:

  • know or believe that they are a beneficiary under the client’s will, or that they will benefit in any other way from the client’s death
  • be an owner or operator of a health care facility where the client lives or is receiving care
  • be a caregiver for the client, unless that is their primary occupation for which they are paid

Proxy for Signing Consent if the Client Requesting Medical Assistance in Dying is Unable to Sign (Criminal Code s. 241.2(4))

If the client requesting MAiD has the mental capacity to make a free and informed decision with respect to their health, but is physically unable to sign and date the request for MAiD, another person may sign in the client’s presence, on the client’s behalf, and under the client’s express direction. The person acting as a proxy must:

  • be at least 18 years of age
  • understand what it means to request MAiD, and
  • not know or believe that they are a beneficiary under the client’s will, or that they will benefit in any other way from the client’s death.

Waiver of Final Consent (Criminal Code s. 241.2(3.2))6

As of March 17, 2021, the requirement for the client to confirm their final consent immediately before receiving MAiD may be waived for a client whose natural death is reasonably foreseeable, in the event that the client loses the capacity to consent before MAiD is provided, provided that:

  • the client has been assessed and approved to receive MAiD
  • the client is at risk of losing decision-making capacity before their preferred date to receive MAiD, and the assessor-prescribed has informed them of that risk
  • the client makes an arrangement in writing with the assessor-prescriber to waive final consent, under which the assessor-prescriber will administer MAiD on their preferred date if they have lost the capacity to provide final consent at that time

The agreement to waive final consent will be invalid if the client, after having lost decision-making capacity, demonstrates refusal or resistance to the administration of MAiD by words, sounds or gestures. Reflexes and other types of involuntary movements, such as a response to a touch or to the insertion of a needle, do not constitute refusal or resistance.

Advance Consent for MAiD by Self-Administration (Criminal Code s. 241.2(3.5))7

As of March 17, 2021, clients approved to receive MAiD who choose to self-administer the substance for MAiD may also make an arrangement in writing with the assessor-prescriber if complications arise after the ingestion of the substance, causing loss of decision-making capacity but not death.

Such arrangements allow the client to provide their consent in advance to practitioner-administered MAiD, in the event of complications with self-administration, and if the practitioner is present at the time of self-administration. All clients who choose to self-administer a substance for the purpose of MAiD can make such an arrangement with the assessor-prescriber, regardless of their prognosis.

Reporting Requirements

For the purpose of oversight or monitoring of MAiD, there are specific requirements and timeframes for reporting MAiD information. Reporting requirements that may apply to nurse practitioners include the following situations:

  • Transfer of care in response to a written request
  • Withdrawal of request by the client
  • Completion of a MAiD eligibility assessment
  • Determination of ineligibility
  • Death of client from another cause
  • Provision of MAiD by administering a substance
  • Provision of MAiD by prescribing or providing a substance for self-administration

For more information on reporting requirements and timeframes, visit the BC Ministry of Health Medical Assistance in Dying website.

Footnotes

1 Nurse practitioners aiding in the provision of medical assistance in dying by a medical practitioner or nurse practitioner will adhere to the standards for medical assistance in dying identified in the Scope of Practice for Registered Nurses: Standards, Limits and Conditions.
2 See also: Justice Canada. (2021, March 19). Canada’s new medical assistance in dying (MAID) law. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html
3 See also: Justice Canada. (2021, March 19). Canada’s new medical assistance in dying (MAID) law. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html
4 See also: Justice Canada. (2021, March 19). Canada’s new medical assistance in dying (MAID) law. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html
5 See also: Health Canada. (2021, March 18). Medical assistance in dying. https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html
6 See also: Justice Canada. (2021, March 19). Canada’s new medical assistance in dying (MAID) law. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html
7 See also: Justice Canada. (2021, March 19). Canada’s new medical assistance in dying (MAID) law. https://www.justice.gc.ca/eng/cj-jp/ad-am/bk-di.html

Next: MAiD Standards >>

Each BCCNM designation has its own set of Standards of Practice.

900 – 200 Granville St
Vancouver, BC  V6C 1S4
Canada

info@bccnm​.ca
604.742.6200​
​Toll-free 1.866.880.7101 (within Canada only)