An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying) (referred to as The Act in this document) received Royal Assent on June 17, 2016 introducing legislation that allows a person to request and receive medical assistance in dying in Canada under limited circumstances. This legislation revises the Canadian Criminal Code to include exemptions for health-care providers who may help to provide medical assistance in dying under the direction of a physician or nurse practitioner.
This resource provides nurses with guidance about their accountabilities related to The Act and medical assistance in dying.
The Act defines medical assistance in dying as:
(a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or
(b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.
The Act revises the Canadian Criminal Code to include exemptions from otherwise applicable criminal offenses for health-care providers who help to provide medical assistance in dying in defined circumstances. Only physicians or nurse practitioners may directly provide a person with medical assistance in dying.
On June 17, 2016, The Act passed Royal Assent and became law.
The Alberta Health ministerial directive D3-2016 outlines that Alberta Health Services (AHS) shall coordinate and facilitate access to health services relating to medical assistance in dying in Alberta. Anyone that is seeking additional information related to medical assistance in dying may be referred to their physician, nurse practitioner or can contact Health Link at 811 or contact the AHS Medical Assistance in Dying Care Coordination Team at MAID.CareTeam@ahs.ca.
Only physicians or nurse practitioners can assess a client’s eligibility for and provide medical assistance in dying. The Act outlines the criteria required for the eligibility of medical assistance in dying. It states:
Eligibility for medical assistance in dying
(1) A person may receive medical assistance in dying only if they meet all of the following criteria:
(a) they are 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;
(b) they are at least 18 years of age and capable of making decisions with respect to their health;
(c) they have a grievous and irremediable medical condition;
(d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and
(e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.
Grievous and irremediable medical condition
(2) A person has a grievous and irremediable medical condition only if they meet all of the following criteria:
(a) they have a serious and incurable illness, disease or disability;
(b) they are in an advanced state of irreversible decline in capability;
(c) that illness, disease or disability or that state of decline causes them enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable; and
(d) their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.
The passing of The Act allows nurses to participate in medical assistance in dying when under the direction of a physician or nurse practitioner. It is essential for nurses to understand that the RN will have a limited role in medical assistance in dying. Only a physician or nurse practitioner may administer the substance that causes the death. We recommend that any nurse who has been asked to participate in medical assistance in dying contact their regulatory college for advice.
We have been collaborating with Alberta Health, Alberta Health Services, the College of Physicians and Surgeons of Alberta, and the Alberta College of Pharmacists to develop a regulatory framework for medical assistance in dying (MAID) that is aligned, legally sound, safe and consistent with the amended Criminal Code. This framework includes additional provincial safeguards for consistency and patient safety.
Through an Order in Council, Alberta Health in conjunction with CARNA, has developed the NP Medical Assistance in Dying Standards of Practice that NPs providing MAID must meet. If you have any questions, please contact us at email@example.com.
End of life care with the goal of a peaceful death has always been a role of nursing. Nurses engage in conversations about end of life and help clients facilitate and navigate information to assist them in making informed decisions. This role has not changed. The passing of The Act allows nurses to participate in medical assistance in dying when under the direction of a physician or nurse practitioner. Nurses that assist in medical assistance in dying when under the direction of a physician or NP must ensure the following requirements are met:
Nurses considering any involvement in medical assistance in dying should contact their regulatory college and the Canadian Nurses Protective Society at 1.800.267.3390 for advice.
Considerations for nursing practice
Despite the authorization to provide nursing care in medical assistance in dying, nurses must always restrict themselves to activities which they are competent to perform and that are appropriate to their area of practice and the procedures being performed.
Below are some considerations for nursing practice in regards to medical assistance in dying.
Route of administration
Acknowledge the request for information in a competent and compassionate way. Know that your client’s request for additional information or further consultation on medical assistance in dying is their constitutional right and as nurses we can support their access to accurate and objective information so that they may make an informed decision about their care. Be aware that a request for information on assisted death may also be a way for the client to engage in a meaningful conversation about health issues or end of life care and support.
The Act indicates:
“For greater certainty, no social worker, psychologist, psychiatrist, therapist, medical practitioner, nurse practitioner or other health-care professional commits an offence if they provide information to a person on the lawful provision of medical assistance in dying.”
Whether or not a nurse chooses to participate in medical assistance in dying, he/she has an obligation to:
The Alberta Health ministerial directive D3-2016 outlines that Alberta Health Services shall coordinate and facilitate access to health services relating to medical assistance in dying. Anyone that is seeking additional information related to medical assistance in dying may be referred to their physician, nurse practitioner or can contact Health Link at 811 or contact the AHS Medical Assistance in Dying Care Coordination Team via email at MAID.CareTeam@ahs.ca.
Nurses should only provide information on medical assistance in dying on the client’s explicit request. Nurses should not initiate a discussion on medical assistance in dying with clients because this could be interpreted as counseling a person to die or the client may feel pressured. Nurses who provide information about medical assistance in dying should ensure that the information is correct before it is provided and should not guess or speculate. Where unsure, the nurse should consult with reliable sources of information and may wish to consider an early referral to authoritative sources of information such as the Alberta Medical Assistance in Dying Care Coordination Team. Nurses should also endeavor to remain as neutral as possible and refrain from advocating for or against medical assistance in dying.
In addition, the nurse must be aware that there are new criminal offences with serious penalties for tampering with documents related to medical assistance in dying.
Highlight to your client that nurses:
Engage the client in meaningful communication to clearly understand their health needs. Continue your nursing assessments and provide care as you always would with empathy, respect and compassion. Reinforce your commitment to support and help them with their care needs and any decisions they make. Your nursing role is to continue providing safe, competent, compassionate, ethical nursing care.
Nurses are not required to participate in medical assistance in dying if it is in conflict with their moral beliefs and values (conscientious objection). Legislation does not force any person to provide or help in the provision of medical assistance in dying.
If you are asked to participate in any aspect of lawful medical assistance in dying and you choose not to participate due to reasons of conscience, ensure you immediately:
Reassure the client that they will not be abandoned. No personal moral judgments about the beliefs, lifestyle, identity or characteristics of the client should be expressed by the nurse. Until a replacement caregiver is found, a nurse must continue to provide nursing care, as per a client’s care plan, that is not related to activities associated with medical assistance in dying.
The issue of ending life raises many ethical considerations and generates differences of opinion. Because clients may make choices that challenge or conflict with the moral values of health professionals who care for them, it becomes necessary to recognize the rights of all persons with conflicting views with the care team. Nurses need to respect their own moral beliefs while at the same time respecting the moral beliefs of others.
If you have any questions about conscientious objection, please contact your professional regulatory college for information.
The Act outlines that a request for medical assistance in dying must be signed by two independent witnesses. Health-care providers who provide care to the recipient of medical assistance in dying are not permitted to act as independent witnesses under section 241.2(5). Nurses involved in providing health-care services or personal care to the person making the request cannot act as an independent witness. The Act states:
(5) Any person who is at least 18 years of age and who understands the nature of the request for medical assistance in dying may act as an independent witness, except if they
(a) know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person’s death;
(b) are an owner or operator of any health-care facility at which the person making the request is being treated or any facility in which that person resides;
(c) are directly involved in providing health-care services to the person making the request; or
(d) directly provide personal care to the person making the request.
Familiarize yourself with federal and provincial regulations, professional regulatory college standards and guidelines and organizational policies on medical assistance in dying. Participate in and provide feedback to provincial, organization, professional and local work area surveys. Participate in conversations on this topic with your team to promote understanding. Call your professional regulatory college with any questions.
CARNA has been part of a nursing working group consisting of the three nursing regulators in Alberta to establish collaborative guidance and support for nursing members. We are currently developing collaborative guidelines for MAID.
CARNA is also working with Alberta Health and Alberta Health Services to recognize the role of all nurses in medical assistance in dying and collaborate to achieve the necessary legal protection, standards of practice and education.
Earlier this year, more than 2,500 RNs, NPs and stakeholders contributed their views and feedback on medical assistance in dying through a Thoughtexchange consultation. View this interactive report to see what respondents had to say.