Medical Assistance in Dying (MAiD)

Medical Assistance in Dying (MAiD) was approved in Canada in June 2016, allowing for a legal pathway for Canadians to pursue and receive physician-assisted suicide.

• Suicide was part of the Canadian Criminal Code starting in 1892, meaning anyone found guilty of committing suicide or aiding in suicide could be incarcerated
• Suicide was decriminalized in 1972 as part of greater psychiatric reforms
• Aiding in suicide remained criminal until physician-assisted suicide was decriminalized in 2015

In Canada, an individual must meet all of the following criteria:

1. Be 18 years of age or older and have decision-making capacity
2. Be eligible for publicly funded health care services
3. Make a voluntary request that is not the result of external pressure
4. Give informed consent to receive MAID, meaning that the person has consented to receiving MAID after they have received all information needed to make this decision
5. Have a serious and incurable illness, disease or disability (excluding a mental illness until March 17, 2024)
6. Be in an advanced state of irreversible decline in capability
7. Have enduring and intolerable physical or psychological suffering that cannot be alleviated under conditions the person considers acceptable

An approach to conversation about MAiD may look something like this:^[1]

1. Patient directly or indirectly initiates discussion of MAiD
   • “Can’t you just give me something so I won’t suffer?”
   • “I want to know about MAiD.”
   • “Can you help me end my life?”
   • “What are all my options and alternatives?”
2. Care professional responds and clarifies the patient’s interest in MAiD
   • “Are you asking for help to die?”
   • “Are you looking for more information about MAiD?”
   • “Tell me what a “good death” looks like to you.”
   • “Are you asking about medical assistance in dying or something else?”
3. Care professional ensures patient has opportunity to explore their care options
   • “Do you need more information about your condition or your options?”
   • “What are your most important goals if your health situation worsens?”
   • “What more can I do for you?”
   • “Has anyone talked to you about treatment options to address your goals and worries?”
   • “Tell me about your suffering.”
   • “What are your biggest fears and worries about the future with your health?”
   • “Can I help you with anything else?”
4. Care professional informs about the MAiD process
   • “I’ll get you a brochure that explains the MAiD request process”
   • “Let me get the Social Worker here to talk about what’s involved.”
   • “What questions do you have about the process?”
   • “MAID [is/is not] provided at this facility and we will always provide the best possible care to you no matter what decision you make.”
5. Care professional provides regular care
   • “I know you are considering MAiD. Let’s talk about what we can do to alleviate your suffering right now while you explore your options.”
   • “I understand you are pursuing MAiD. Let’s talk about what treatments and services will help you stay as comfortable and well as possible during this process.”

• Components of a MAID capacity consult
  • Medical diagnosis
  • Eligibility
  • Determination of a grievous and irremediable medical condition
  • Voluntariness: Ensure there is no coercion. MAID is the patient's decision. Speak with the patient's primary physicians and family members.
  • Capacity (is the patient capable of consenting to MAID?):
    • What is the patient's understanding of MAID?
    • Do they understand the MAID process?
    • Is the patient aware of other options (e.g. - analgesia, physiotherapy, home care, residential facilities)
  • Clinician's declaration:
    • The clinician should state they are not a beneficiary under the will of this patient or a recipient of financial or material benefits resulting from the patient's death
    • The clinician should state they are not mentor or supervisor to the intervention (MAID provider) physician or connected in any way that would affect objectivity

• USA: Terminal illness required
• Europe: Only intolerable suffering required

• USA, Switzerland: self-administered only
• Canada, Netherlands: self-administered or euthanasia (doctor performed)

• USA: Required if patient has depression
• Belgium: Required if prognosis > 1 year

• CMPA: Medical assistance in dying (MAID)
• CMPA: The continuing evolution of medical assistance in dying

• Nayyar, D., Kawaguchi, S., & Mah, B. (2019). Request for medical assistance in dying after a suicide attempt in a 75-year-old man with pancreatic adenocarcinoma. Canadian Medical Association. Journal, 191(30), E838-E840.