On-Line System Category
POLICY AND
PROCEDURE
Subject: MEDICAL
Not applicable
ASSISTANCE IN DYING (MAID)
Issued by:
MEDICAL ADVISORY COMMITTEE
Code No
Page 1
of 4
Date Effective: June 9, 2016
Date Reviewed: March, 2017
Date Revised: March 2017
Approved by:
Medical Advisory Committee - March 7, 2017
Senior Management Team – March 23, 2017
PURPOSE:
To ensure a consistent and effective response to patient requests for Medical Assistance in Dying (MAID)
POLICY:
1. OSMH will respond to patient requests for MAID in a comprehensive, timely and patient focused manner, in
accordance with current legislation and regulatory college guidelines and policies.
2. Conscientious objections will be respected for any staff or credentialed staff by providing access to
clinicians who are willing to provide MAID.
3. The utmost confidentiality will be maintained for any requests, in order to protect patients and providers
and the hospital from unwanted media or public attention.
PROCEDURE:
Responsibility:
Physicians (MD)
Nurse Practitioners (NP)*
Nurses
Pharmacists
CCAC
Ethics Committee members
Social Workers(SW)
Pastoral Care personnel
Respiratory Therapists (RT)
Speech-Language Pathologists (SLP)
Staff members
*until enabling legislation for prescribing is enacted, NPs may participate as the independent consultant only
Method:
Any staff member who becomes aware of a patient request for Medical Assistance in Dying will inform the patient’s
nurse at the earliest opportunity.
STAGE 1: PATIENT REQUESTS MEDICAL ASSISTANCE IN DYING- REFER TO MOHLTC CLINICIAN AID “A”
NURSES –

respond to the patient’s request by acknowledging and clarifying their request directly and confidentially
with the patient

inform the patient of this Policy and Procedure

inform the Most Responsible Physician (MRP) of the patient’s request

document the request
PHYSICIANS AND NURSE PRACTITIONERS:
MOST RESPONSIBLE PHYSICIAN OR NURSE PRACTITIONER

Provide patient with MOHLTC MEDICAL ASSISTANCE IN DYING Information for Patients

If the patient’s care plan can be safely transitioned to the home or community setting, refer to CCAC and
community MAID provider and begin discharge planning.
“Disclaimer: Printed copies of this document must be validated with the approved
online version prior to each use.”
On-Line System Category
POLICY AND
PROCEDURE
Subject: MEDICAL
MEDICAL ADVISORY COMMITTEE








Not applicable
ASSISTANCE IN DYING (MAID)
Issued by:
Code No
Page 2
of 4
Date Effective: June 9, 2016
Date Reviewed: March, 2017
Date Revised: March 2017
Approved by:
Medical Advisory Committee - March 7, 2017
Senior Management Team – March 23, 2017
If the patient’s care needs require ongoing hospital care , proceed as below:
review current regulatory college guidelines and/or policies regarding End of Life Care and Medical
Assistance in Dying
seek any advice necessary in order to confidently respond to the patient’s request (legal, ethical, practical)
assess and document the patient’s capacity for decision making
for a patient without capacity for decision making, decline the request
for a person with capacity for decision making, open a dialogue with the patient about the request
ensure that barriers to communication are addressed (eg. SLP assessment and intervention,
communication aids, translation services)
ensure that the patient has information about all available options for ongoing care including disease
management, pain and symptom management, hospice palliative care and end of life care.

determine that the person meets the criteria for MAID:
1. eligible – or, but for any applicable minimum period of residence or waiting period, would be
eligible – for health services funded by a government in Canada.
2. At least 18 years of age and capable of making decisions with respect to their health
3. Has a grievous and irremediable medical condition –
A person has a grievous and irremediable medical condition if:

They have a serious and incurable illness, disease or disability

They are in an advanced state of irreversible decline in capability

That illness, disease or disability or that state of decline causes them enduring physical or
psychological suffering that is intolerable to them and cannot be relieved under conditions that
they find acceptable
4. Has made a voluntary request for medical assistance in dying that, in particular, was not made as a
result of external pressure
5. They give informed consent to receive medical assistance in dying

offer to the patient and family consultations with Ethics, Palliative Care, Pastoral Care, Pharmacy, Social
Work
advise the patient to attend to their final affairs (legal, financial, funeral, burial, etc), and to seek
appropriate advice to do so
inquire if there is another physician the patient would like to be consulted (eg. family physician if not the
MRP, specialist with knowledge of the patient’s condition)
initiate communication among the MRP, the Nurse, and other team members as required, including but not
limited to Ethics, Social Work, Pastoral Care, family members and others as requested by the patient.
determine the patient’s preferred place of death (hospital, home)
if the patient is requesting MAID at home, consult CCAC
document the patient’s request for MAID
document the patient’s condition and experience of irremediable and intolerable suffering
inform the person that their natural death has become reasonably foreseeable, taking into account all their
medical circumstances








OTHER PROFESSIONALSCCAC, ETHICS, PALLIATIVE CARE, PASTORAL CARE, PHARMACY, SOCIAL WORK

Available team members, when requested, will provide information and support to the patient, family,
nurse and MRP.
STAGE 2: PRIOR TO THE PROVISION OF MEDICAL ASSISTANCE IN DYING –
“Disclaimer: Printed copies of this document must be validated with the approved
online version prior to each use.”
On-Line System Category
POLICY AND
PROCEDURE
Subject: MEDICAL
Not applicable
ASSISTANCE IN DYING (MAID)
Issued by:
MEDICAL ADVISORY COMMITTEE
Code No
Page 3
of 4
Date Effective: June 9, 2016
Date Reviewed: March, 2017
Date Revised: March 2017
Approved by:
Medical Advisory Committee - March 7, 2017
Senior Management Team – March 23, 2017
PHYSICIAN OR NURSE PRACTITIONER PROVIDING MAID: REFER TO MOHLTC CLINCICIAN AID “B”
WRITTEN REQUEST AND WITNESSES

obtain informed consent from the patient and require that the request be provided in writing on the
prescribed form, signed and dated by the patient and witnessed and dated by two independent witnesses
 Refer to Bill C14, appended, regarding Independent Witnesses

if the person requesting medical assistance in dying is unable to sign and date the request, another person,
who is 18 years of age and who understands the nature of the request may do so in the person’s presence
on their behalf.

answer questions from the patient and family about the procedure, what to expect

plan for a period of reflection prior to a second request
 10 clear days or- if the consulting medical practitioner or nurse practitioner are both of the opinion
that the person’s death, or the loss of their capacity to provide informed consent is imminent –any
shorter period the first medical practitioner or nurse practitioner considers appropriate in the
circumstances

respond to second request by proceeding to Stage 3, below
INDEPENDENT CONSULTING PHYSICIAN OR NURSE PRACTITIONER: REFER TO MOHLTC CLINICIAN AID “C”
 refer to Bill C14 (6) a-c, appended, re Independent Practitioner
A second independent physician or nurse practitioner is required to ensure that the person meets the criteria
above, and to:

assess the patient for capacity and voluntariness

refer the patient for a specialized capacity assessment if the person’s competence is in question

independently document an opinion that the criteria for MAID have been met

in the case of differing opinions, inform the patient that they are entitled to have another consulting
physician assess them against the criteria

remind the patient that they can rescind their request for MAID at any time
STAGE 3: PROVISION OF MEDICAL ASSISTANCE IN DYING(MAID)
In order to protect patients, families and participants from unwanted public or media attention, the
utmost confidentiality will be upheld by all staff, credentialed staff, participants and volunteers in the
planning and delivery of the MAID.
PHYSICIAN or NURSE PRACTITIONER PROVIDING MAID:

consult OSMH Resource Group for any support needed

ensure that another independent medical practitioner or nurse practitioner has provided a written opinion
confirming that the person meets all of the criteria for MAID.

with the patient, plan communication with affected family and team members

consult with Pharmacy on available drugs and dosing protocols

with the patient, family, nurse and pharmacist, plan date and time of procedure, and confirm who will be
there

remind all participants and team members of the need for confidentiality

review and confirm informed consent for the procedure

write orders for the drug protocol, using OSMH Order set

ensure MAID MOHLTC Forms A,B,C are complete

immediately before providing MAID, give the person an opportunity to withdraw their request and ensure
that the person gives express consent to receive medical assistance in dying.

participate in the procedure as indicated by the selected protocol (to be appended)
“Disclaimer: Printed copies of this document must be validated with the approved
online version prior to each use.”
On-Line System Category
POLICY AND
PROCEDURE
Subject: MEDICAL
MEDICAL ADVISORY COMMITTEE


Not applicable
ASSISTANCE IN DYING (MAID)
Issued by:
Code No
Page 4
of 4
Date Effective: June 9, 2016
Date Reviewed: March, 2017
Date Revised: March 2017
Approved by:
Medical Advisory Committee - March 7, 2017
Senior Management Team – March 23, 2017
attend and certify the death and file information as per Stage 4, below
follow up with family members as appropriate
PARTICIPATING NURSES

provide nursing care and support to the patient and family within scope of practice

assess or start intravenous access if required

move to private room and take measures to increase privacy for the patient and participants

assist physician with safety practices such as independent double checks

notify Trillium Gift of Life of impending death

call a PAUSE immediately before provision of MAID to confirm MAID MOHLTC CLINICIAN AID Forms A,B,C
are complete
PARTICIPATING PHARMACISTS

ensure availability of drugs and doses required for the selected protocol

assist physician with instructions for drug administration
OTHER PROFESSIONALS- ETHICS, PASTORAL CARE, SOCIAL WORK

Support team, patient and family prior, during and after the procedure.

Plan a debrief with the participants to :
o Offer support for providers
o Identify any improvements required in the process

Report any recommendations from the debrief to the OSMH Resource Group.
STAGE 4: CERTIFICATION OF DEATH AND FILING OF INFORMATION
All MAID deaths are reportable to the Regional Coroner’s office.
The Physician providing MAID will notify the Regional Coroner’s Office at the completion of the procedure when
death has occurred.
The physician and the pharmacist will provide any required documentation to the Coroner, the Minister of Health or
designate according to regulations. (Bill C-14 241.31(3) (a-d)
Special Considerations:
Age of patient –

At this time the legislation applies to competent adults 18 years or older
Conscientious Objectors –

some professionals may not agree with MAID. Their responsibilities to their patients are reflected in
regulatory college documents.

the OSMH Resources Group will be available to consult for patients whose MRP or Nurse may
conscientiously object to participation in the procedure. The MRP, if a conscientious objector, will decide at
what stage above the patient requires a referral to a physician or nurse practitioner willing to provide MAID

Any member of the clinical team may make a referral to the OSMH Resource Group for assistance.
Resources
1. OSMH Ethics Committee
2. OSMH Resource Group for MAID
3. Medical Aid in Dying Practice Guidelines, College des Medicins du Quebec 11/2015
“Disclaimer: Printed copies of this document must be validated with the approved
online version prior to each use.”
On-Line System Category
POLICY AND
PROCEDURE
Subject: MEDICAL
Not applicable
ASSISTANCE IN DYING (MAID)
Issued by:
MEDICAL ADVISORY COMMITTEE
Code No
Page 5
of 4
Date Effective: June 9, 2016
Date Reviewed: March, 2017
Date Revised: March 2017
Approved by:
Medical Advisory Committee - March 7, 2017
Senior Management Team – March 23, 2017
References:
Bill C-14- An act to amend the Criminal Code and to make related amendments to other Acts (medical assistance
in dying) April 14, 2016
College of Physicians and Surgeons of Ontario
http://www.cpso.on.ca/Policies-Publications/Policy/Interim-Guidance-on-Physician-Assisted-Death
Drug Protocols are in the Members password protected area of CPSO website
Canadian Medical Protective Association
https://www.cmpa-acpm.ca/web/guest/-/what-the-supreme-court-of-canada-decision-on-physician-assisteddying-means-for-physicians
Canadian Medical Association https://www.cma.ca/en/Pages/cma_default.aspx#
Joint Centre for Bioethics http://jcb.utoronto.ca/news/documents/JCB-PAD-Implementation-Task-ForceKey-Considerations.pdf
MAID Policy
Consultation and Tracking Record - Mar-17.pdf
“Disclaimer: Printed copies of this document must be validated with the approved
online version prior to each use.”