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Introduction

In accordance with the Criminal Code and provincial legislation, under certain limited circumstances, nurse practitioners may provide a client with medical assistance in dying (MAiD).

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

In addition to meeting these Scope of Practice Standards, nurse practitioners contemplating participation in medical assistance in dying need to confer with their employer about their employer's requirements.

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

End of Life Care

There is an important distinction between the intended outcomes of medical assistance in dying and palliative care. 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, and competent manner. Medical assistance in dying is not an appropriate alternative for a client who is seeking palliative care.

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 as an end of life option to clients. However, directing, counselling or recommending a client to end their life remains an offence under the Criminal Code.

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 practitioner20

Transfer of Request for Care

Any nurse practitioner receiving a written request for MAiD who transfers the care of the client to another provider or care coordinator 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.

Nurse practitioners with a conscientious objection 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

Nurse practitioners with a conscientious objection must 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, nurse practitioners must inform those most directly involved in the care of the client of their conscientious objection.

Determining Eligibility for Medical Assistance in Dying

Under the Criminal Code, the process for providing medical assistance in dying requires the assessment of two independent assessors. One of the assessors must be the person prescribing and administering the medical assistance in dying substances (or prescribing the substances for self-administration [i.e., the assessor-prescriber]). Only a nurse practitioner registered in British Columbia or a medical practitioner may be an assessor or assessor-prescriber.

Both the assessor-prescriber and the second assessor must agree in writing that the client requesting medical assistance in dying meets the criteria for MAiD as set out by the Criminal Code, which includes that the client has a grievous and irremediable medical condition causing suffering that is intolerable to the client. A request for medical assistance in dying is contextual to the client's medical condition, its natural history and prognosis, treatment options and the risks and benefits associated with each option. Nurse practitioners are responsible to ensure that the client requesting medical assistance in dying understands such factors and is able to communicate a reasoned decision based on that understanding.

Under the Criminal Code, both the assessor-prescriber and the second assessormust be independent of each other. To be considered independent, each of the assessors must:

  • not be a mentor to the other practitioner or responsible for supervising their work
  • not know or believe that they are a beneficiary under the will of the client making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that client's death, other than standard compensation for their services relating to the request
  • not know or believe that they are connected to the other assessor or to the client making the request in any other way that would affect their objectivity.

Witnessing Requests for Medical Assistance in Dying

The Criminal Code requires that a client's request for medical assistance in dying must be made in writing, in the presence of two independent witnesses who must then also sign the request.

To be considered independent, a witness:

  • must be at least 18 years of age
  • must understand the nature of the request for medical assistance in dying
  • must not know or believe that they are a beneficiary under the will of the client making the request, or that they will receive, in any other way, any financial or other material benefit resulting from the client's death
  • must not be an owner or operator of any health care facility at which the client making the request is being treated or any facility in which that person resides
  • must not be directly involved in providing health care services to the client making the request
  • must not directly provide personal care to the client making the request

Proxy for Signing Consent if the ClientRequesting Medical Assistance in Dying is Unable to Sign

The Criminal Code requires that if the client requesting medical assistance in dying 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 medical assistance in dying, 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 the nature of the request for medical assistance in dying, and
  • not know or believe that they are a beneficiary under the will of the client making the request, or that they will receive, in any other way, any financial or other material benefit resulting from the client's death.

Reporting Requirements

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

  • Transfer of care in response to a written request
  • Withdrawal of request by the client
  • 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, please visit the BC Ministry of Health Medical Assistance in Dying website.

Footnotes

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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.

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