Medical Asistance in Dying: Standards

1. Nurse practitioners participating in any aspect of MAiD comply with the Criminal Code of Canada and other applicable legislation, BCCNM standards of practice, and provincial and organizational policies and p​​rocedures related to MAiD.

2. Nurse practitioners use and follow the applicable provincial forms, prescriptions, and guidelines specific to MAiD.

3. Nurse practitioners acting as an assessor or assessor-prescriber for MAiD must have the competence appropriate to their role, including the competence to:

   a.	Diagnose or confirm the diagnosis of a grievous and irremediable medical condition and, if applicable, the prognosis of reasonably foreseeable death.
   b.	Assess the client against criteria in the Criminal Code of Canada related to MAiD.
   c.	Assess the capacity of the client to consent to MAiD and determine when it is necessary to refer for further capacity assessment.
   d.	Implement the provincial MAiD substances protocols and manage the intended and unintended outcomes.

4. Nurse practitioners a​​cting as assessor or assessor-prescriber for MAiD apply the Indigenous Cultural Safety, Cultural Humility, and Anti-Racism Practice Standard in the context of MAiD, as applicable​.

   Determining eligibility ​​
   

5. ​​When advisin​g anyone about ​​their potential eligibility for MAiD, nurse practitioners:
   

a.	Have a complete and full discussion with the person about MAiD that provides them with the information they need to make an informed decision, including the information required by the Criminal Code of Canada(sections 241.2(1)(e) and 241.2(3.1)(g)),30  and
b.	​​Take reasonable steps to ensure the person does not perceive coercion, inducement, or pressure to pursue or not to pursue MAiD.

6. Nurse practitioners acting as an assessor-prescriber must ensure cleints requesting MAiD meet the eligibility criteria set out in the Criminal Code of Canada(section 241.2(1) and (2)).^31​

7. Nurse practitioners acting as an assessor or asse​ssor-prescriber determine eligibility only when all the health information required is obtained and complete, including collateral information³²  necessary for the completion of a MAiD assessment.³³  
   

8. Nurse practitioners acting as an assessor or assessor-prescriber must en​sure that:

   a.	The client requesting MAiD has the capacity to give free and informed consent to MAiD. Consent cannot be given for MAiD through an alternate or substitute decision-maker or a personal advance directive.
   b.	Both assessors are satisfied that the client has the capacity to make a free and informed decision with respect to MAiD at the time of the request.
   c.	Th​e client is referred to another practitioner with expertise in capacity assessment—such as a psychologist, psychiatrist, neurologist, geriatrician, or family physician/general practitioner with addi​tional training and expertise—for a further capacity assessment if either assessor is unsure that the client has the capacity to consent to MAiD.

9. Nurse practitioners assess the cultural and spiritual needs and wishes of the client seeking MAiD and explore ways the client’s needs could be met within the context of the care delivery​.
   

10. Nurse practitioners ensure that the client requesting MAiD receives high quality, coordinated, and uninterrupted continuity of care and, if needed, safe transfer of the client’s care to another health care provider.
    

11. Nurse practitioners ensure that the client’s request for MAiD​:
    

    a.	Aligns with the client’s values and beliefs,
    b.	Is clear,
    c.	Is enduring, and
    d.​	​Is made during a period of stability rather​ than crisis.34​

12. Nurse practitioners acting as an assessor or assessor-prescriber complete a suicide risk assessment for clients who are determined to be ineligible for MAiD and  make appropriate referals for suicide prevention supports and services based on the findings of the risk assessment.³⁵
    

13. Nurse practitioners acting as an assessor or assessor-prescriber must be familiar with and adhere to any provincial or federal requirements relating to MAiD for clients who are being involuntarily treated under the Mental Health Act (Section 22) or who or are incarcerated at the time of requesting MAiD.
    

    Procedural safeguards ​​

14. Nurse practitioners acting as an assessor-prescriber must comply with all applicable procedural safeguards set out in the Criminal Code of Canada (section 241.2(3) and (3.1))³⁶ before prescribing, providing, or administering MAiD to a client​​.
    

15. Immediately before providing MAiD, the nurse practitioner acting as an assessor-prescriber must give the client an opportunity to withdraw their request and ensure that the client gives express consent to receive MAiD, unless they meet the criteria in the Criminal Code of Canada for waiver of final consent (section 241.2(3.2) or (3.5)).³⁷
    

    Virtual assessment

16. Nurse practitioners acting as an assessor or assessor-prescriber may provide their assessment virtually if they comply with the following conditions​:
    

    a.	Nurse practitioners ensure that during the virtual assessment, another regulated health professional is physically present with the client to act as a witness to the assessment, unless no other regulated health professional is reasonably available to attend in person.
    b.	Virtual assessments must meet the requirements set out in federal legislation and all other standards and expectations that apply to in-person assessments.
    c.	Virtual assessments must include video of sufficient quality to ensure expected safeguards are in place.

    Administering MAiD

17. Nurse practitioners acting as an assessor-prescriber must receive the substances for MAiD directly from the dispensing pharmacist, and must inform the dispensing pharmacist that the substances are intended fo​r MAiD​.
    

18. Nurse practitioners acting as an assessor-prescriber must personally attend the client during the self-administration or personally administer the substances for MAiD  and must remain in attendance until death is confirmed. This responsibility must not be delegated or assigned to any other person.
    

19. Nurse practitioners acting as an assessor-prescriber are responsible for ensuring that any unused substances are returned to the pharmacy as soon as reasonably feasible, and within 72 hours of confirmation of the client’s death.
    

    a.

    If a nurse practitioner acting as an assessor-prescriber is not reasonably available to return unused substances to the pharmacy themselves, they may ask another nurse practitioner, or a licensed practical nurse, registered nurse, registered psychiatric nurse, physician, or pharmacist to return the substances to the pharmacy. The nurse practitioner must document the name of the person assigned to return the substances in the client record.​

    Documentation and reporting

20. Nurse practitioners communicate with the client requesting me​dical assistance in dying, and document in the medical record with a co​py provided to the client:

    a.	The clien​t's diagnosis and prognosis,​
    b.	Feas​​ible alternatives to relieve suffering (including palliative care, pain control, and other services and supports),
    c.	Option to withdraw the request for medical assistance in dying at any time, and
    d.	Ris​ks of taking the prescribed substances intended to cause death.​

21. Nurse practitioners acting as an assessor-prescriber​ who prescribe^38​ or administer the substances to be used in MAiD must do so in the client's name using the provincial MAiD prescription form.

22. Nurse practitioners act​​ing as an assessor-prescriber complete the medical certificate of death. The medical certificate of death must indicate that the manner of death involved MAiD and that the cause of death is the underlying illness/disease causing the grievous and irremediable medical condition.

23. Nurse practitioners comply with information or medical record requ​ests made by a provincial agency tasked with a review of MAiD.
    

24. Nurse practitioners comply with reporting requirements establis​hed for the oversight or monitoring of MAiD. The required information must be submitted to the B.C. Ministry of Health using the applicable provincial forms and within the established timeframes for reporting.^39​
    

25. Nurse practit​​ioners must ensure the following information is present in the client's medical record:

    a.​​	​All ap​​plicable provincial forms for MAiD, including the B.C. Medical Assistance in Dying Prescription form and Medication Administration Record.
    ​​b.	Copies of​​ all relevant medical records from other medical practitioners/health care professionals involved in the client's care  supporting the diagnosis and prognosis of the client's grievous and irremediable condition, disease, or disability.
    c.	Docume​​ntation of all requests for MAiD with a summary of the discussion.
    d.	Confirma​​tion that the assessor-prescriber and the second assessor discussed and determined which practitioner would prescribe and/or administer the substance used for MAiD.
    ​​e.​	​Confirm​​ation by the assessor-prescriber that all the requirements have been met including the steps taken and the substance prescribed.
    ​​​​f.	​Confirmation that after the completion of all documentation, and just prior to administration, the client was offered the opportunity to withdraw their request, or that the client waived final consent and did ​​not demonstrate refusal or resistance to the administration of MAiD by words, sounds, or gestures.​​

Footnotes

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