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.
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.
Since March 17, 2021, the Criminal Code has established two different sets of safeguards for the provision of MAiD depending on whether the client’s “natural death is reasonably foreseeable” or “natural death is not reasonably foreseeable”.
Advising the client about MAiD
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. Registrants must take reasonable steps to ensure the person does not perceive coercion, inducement, or pressure to pursue or not to pursue MAiD. Advising persons of potential eligibility for MAiD based on professional judgement is distinct from counselling persons to consider MAiD.
The Criminal Code requires that a client requesting MAiD is informed of the means that are available to relieve their suffering, including palliative care. This supports the client requesting MAiD to gather information needed to make an informed decision about their health care options.
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 practitioner23.
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.
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.
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))26
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.
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.
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.
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:
For more information on reporting requirements and timeframes, visit the
BC Ministry of Health Medical Assistance in Dying website.
Footnotes
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