(canada.ca) On March 17, 2021, the Government of Canada announced that changes to Canada’s medical assistance in dying (MAID) law are officially in force. The new law includes changes to eligibility, procedural safeguards, and the framework for the federal government’s data collection and reporting regime.
About medical assistance in dying
Changes to the Criminal Code
In February 2015, the Supreme Court of Canada ruled in Carter v. Canada that parts of the Criminal Code would need to change to satisfy the Canadian Charter of Rights and Freedoms. The parts that prohibited medical assistance in dying would no longer be valid. The Supreme Court gave the government until June 6, 2016, to create a new law.
In June 2016, the Parliament of Canada passed federal legislation that allows eligible Canadian adults to request medical assistance in dying.
On October 5, 2020, the Minister of Justice and Attorney General of Canada introduced Bill C-7: An Act to amend the Criminal Code (medical assistance in dying) in Parliament, which proposes changes to Canada’s law on medical assistance in dying.
On March 17, 2021, Parliament passed revised legislation that makes important changes to who may be eligible to obtain medical assistance in dying and the process of assessment. These changes take effect immediately. The government is working with provinces and territories and with health care professionals to ensure eligible Canadians will be able to request MAID according to the new law, and that the appropriate protections are in place.
Who can provide medical assistance in dying and who can help
Those who can provide MAID are:
- nurse practitioners (in provinces where this is allowed)
Those who can help provide MAID include:
- pharmacists and pharmacy technicians/assistants
- family members or other people that you ask to help
- health care providers who help physicians or nurse practitioners
Those who can help provide medical assistance in dying include:
- family members or other people that you ask to help
- health care providers who help physicians or nurse practitioners
These people can assist in the process without being charged under criminal law. However, physicians, nurse practitioners and other people who are directly involved must follow:
- the rules set out in the Criminal Code
- applicable provincial and territorial health-related laws, rules and policies
Protecting the right of providers to act according to their beliefs and values
Not all health care providers are comfortable with medical assistance in dying. Participating in MAID may not be consistent with a provider’s beliefs and values. The federal legislation does not force any person to provide or help to provide medical assistance in dying.
Provincial and territorial governments have the responsibility for determining how and where health care services are provided. They may also make policies around where MAID can take place, however, they cannot permit actions that are prohibited under the Criminal Code.
Supporting access for patients seeking medical assistance in dying
We understand that these provider rights could create challenges for patients who want to access medical assistance in dying. Patients are encouraged to contact their physician or nurse practitioner (if applicable) for questions about access. Patients may also wish to contact the resources set up within their province or territory to get information on MAID and other care options. (See: Supporting access to a range of care and support options)
Physicians and nurse practitioners are encouraged to contact their provincial or territorial professional regulatory body for information about specific practice guidelines and about their reporting obligations.
Available MAID options
There are 2 types of medical assistance in dying available to Canadians. They each include a physician or nurse practitioner who:
- directly administers a substance that causes death, such as an injection of a drug
- this is becoming known as clinician-administered medical assistance in dying
- provides or prescribes a drug that the eligible person takes themselves, in order to bring about their own death
- this is becoming known as self-administered medical assistance in dying
Which drugs to use are outlined in clinical guidelines and practices established by provinces and territories, or organizations that regulate the practice of medicine.
Many of the drugs commonly used for this procedure are already marketed in Canada and are prescribed at lower dosages for common purposes, such as:
- pain control
As the regulator of drug products, Health Canada will work with partners, as needed, to help support access to drugs for medical assistance in dying.
Who is eligible for medical assistance in dying
New changes to the legislation have allowed a broader group of people to be eligible to request and receive MAID. These changes came into effect on March 17, 2021.
In order to be eligible for medical assistance in dying, you must meet all of the following criteria. You must:
- be eligible for health services funded by the federal government, or a province or territory (or during the applicable minimum period of residence or waiting period for eligibility)
- generally, visitors to Canada are not eligible for medical assistance in dying
- be at least 18 years old and mentally competent. This means being capable of making health care decisions for yourself.
- have a grievous and irremediable medical condition
- make a voluntary request for MAID that is not the result of outside pressure or influence
- give informed consent to receive MAID
Grievous and irremediable medical condition
To be considered as having a grievous and irremediable medical condition, you must meet all of the following criteria. You must:
- have a serious illness, disease or disability (excluding a mental illness until March 17, 2023)
- be in an advanced state of decline that cannot be reversed
- experience unbearable physical or mental suffering from your illness, disease, disability or state of decline that cannot be relieved under conditions that you consider acceptable
You do not need to have a fatal or terminal condition to be eligible for medical assistance in dying.
Canadians whose only medical condition is a mental illness, and who otherwise meet all eligibility criteria, will not be eligible for MAID until March 17, 2023 (see About mental illness and MAID).
To be eligible, you must provide informed consent to your practitioner. This means you have consented (given permission) to MAID after you have received all of the information you need to make your decision, including:
- your medical diagnosis
- available forms of treatment
- available options to relieve suffering, including palliative care
You must be able to give informed consent both:
- at the time of your request
- immediately before MAID is provided unless special circumstances apply (see Waiver of Final Consent).
You can withdraw your consent at any time and in any manner.
About mental illness and MAID
If a mental illness is the only medical condition leading you to consider MAID, you are not eligible to seek MAID at this time. Under the new changes made to the law, the exclusion will remain in effect until March 17, 2023.
This temporary exclusion provides the Government of Canada and health professional bodies more time to consider how MAID can be provided safely to those whose only medical condition is a mental illness.
To support this work, the government initiated an expert review to provide recommendations on protocols, guidance and safeguards for those with a mental illness seeking MAID.
After March 17, 2023, people with a mental illness as their sole underlying medical condition will have access to MAID if they meet all of the eligibility requirements and the practitioners fulfill the safeguards that are put in place for this group of people.
If you have a mental illness along with other medical conditions, you may be eligible to seek MAID.
Eligibility is always assessed on an individual basis, taking into account all of the relevant circumstances. However, you must meet all the criteria to be eligible for medical assistance in dying.
Obtaining medical assistance in dying
Where and how services are provided
Regardless of location, eligible Canadians can request medical assistance in dying.
If you are experiencing a lot of pain and suffering due to your medical situation, talk to your physician or nurse practitioner about options in relation to your medical condition or circumstances and your possible interest in MAID.
If you do not have a regular practitioner, your province or territory may have a central MAID coordination service that can help you with the process.
How and where this service will be offered is determined by:
- provinces and territories
- the organizations that regulate health professionals
- medical institutions
There may be additional requirements that you have to complete. Your health care provider can provide you with more information.
Requesting the service
On March 17, 2021, changes to the legislation on MAID took effect that change existing safeguards for eligible people whose natural death is considered reasonably foreseeable.
The revised law also contains new safeguards for eligible people who are requesting MAID and whose death is not considered reasonably foreseeable.
All safeguards aim to make sure that those who ask for MAID:
- request the service of their own free will
- are able to make health care decisions for themselves
- are eligible (this means they meet all of the criteria above. See: Eligibility)
- can and do give informed consent, which includes being informed of all care options available to them to help relieve suffering
Safeguards guide health care providers to carry out this service appropriately and in a way that protects people from abuse or misuse.
Procedural Safeguards – All Requests for MAID
Undergo medical assessments.
Your request for MAID must be assessed by two independent practitioners.
Your physician or nurse practitioner must make sure that you are eligible to receive medical assistance in dying according to all of the listed criteria.
A second physician or nurse practitioner must also provide a written opinion confirming that you are eligible.
The physician or nurse practitioner providing the original assessment and the one giving the second opinion must be independent.
To be considered independent means that neither of them:
- holds a position of authority over the other
- could knowingly benefit from your death
- is connected to the other or to you in a way that could affect their objectivity
Submit a signed written request for MAID.
For any person, whether your natural death is considered reasonably foreseeable, or not, you must sign a written request that says you want to have a medically assisted death.
Some provinces and territories may require that you complete a specific request form. These forms may be provided by your health care provider or available on a provincial or territorial website.
A written request for MAID must include:
- Your signature confirming your request for MAID. If you are unable to write, another adult can sign the request on your behalf under your clear direction. This adult must:
- be at least 18 years of age
- understand what it means to request MAID
- not benefit from your death (for example, they must not be an heir to your estate)
- Your written request must be signed and dated before one independent witness, who must also sign and date the request.
The role of the independent witness is to confirm to the signing and dating of the request by the person requesting MAID and that they understand what they are signing.
An independent witness must be at least 18 years of age and understand what it means to request MAID.
An independent witness can be a paid professional personal or health care worker.
To be considered independent means that the witness cannot:
- benefit from your death
- be an owner or operator of a health care facility where you live or are receiving care
- be an unpaid caregiver
Withdrawal of your request
You must also be informed of your right to withdraw your request for MAID at any time and in any manner.
You are not obligated to proceed with MAID even if you are found eligible for the service.
Just before receiving MAID, you will also be given a final opportunity to withdraw your request.
Immediately before MAID is provided to you, you must be given the opportunity to withdraw consent, and you must affirm that you consent to receive MAID. An exception to this requirement is possible in the case of people whose deaths are reasonably foreseeable (see Waiver of Final Consent).
Waiver of Final Consent
On March 17, 2021, changes to the legislation on medical assistance in dying allow you to waive the requirement for giving final consent just before MAID is provided, only if:
- while you had decision-making capacity:
- you were assessed and approved to receive MAID
- your practitioner advised that you are at risk of losing capacity to provide final consent
- you made a written arrangement with your practitioner in which you consent in advance to receive MAID on your chosen date if you no longer have capacity to consent on that date
Any arrangement for the waiver of final consent will be considered invalid if, at the time that MAID is to be provided, you no longer have capacity and you demonstrate refusal or resistance to the administration of MAID by words, sounds or gestures.
For further clarity, reflexes and other types of involuntary movements, such as response to touch or the insertion of a needle, would not constitute refusal or resistance.
Waiver of final consent if you choose MAID by self-administration
If you are eligible for MAID and you choose to self-administer prescribed medications for MAID, you may make an arrangement in writing with your practitioner so that they can administer MAID to you in a specific situation.
This specific arrangement allows for practitioner-administered MAID in the event of complications with self-administration that cause your loss of decision-making capacity but not your death. This means that your practitioner must be present at the time that you self-administer the medications.
Procedural Safeguards – Requests where your natural death is not reasonably foreseeable:
If the practitioners assessing your request for MAID determine that your death is not reasonably foreseeable, there are added safeguards that must be met to be eligible to receive MAID:
- One of the two practitioners who provides an assessment must have expertise in the medical condition that is causing your unbearable suffering.
- If neither of these practitioners have this expertise, another practitioner with expertise in your medical condition that is causing your suffering must be consulted in the assessment process.
- You must be informed of available and appropriate means to relieve your suffering, including counselling services, mental health and disability support services, community services, and palliative care, and you must be offered consultations with professionals who provide those services.
- You and your practitioners must have discussed reasonable and available means to relieve your suffering, and all agree that you have seriously considered those means.
- Your eligibility assessment must take a minimum of 90 days, unless the assessments have been completed sooner and you are at immediate risk of losing your capacity to consent.
- Immediately before MAID is provided, the practitioner must give you an opportunity to withdraw your request and ensure that you give express consent to receive MAID.
Implementing the framework – for healthcare providers
Health Canada is providing additional information for healthcare providers that:
- addresses changes to the law, which came into effect on March 17, 2021
- builds on questions from provinces, territories and MAID practitioners
- explains how they can consistently apply the framework to assessments and delivery of MAID
This information is updated periodically.
Roles of the provinces and territories
The federal legislation on medical assistance in dying is part of the Criminal Code. It states that a person is not guilty of a criminal offence if they provide or assist in providing MAID according to the conditions and safeguards in the law.
All health care providers must follow the criminal law.
Provinces and territories may create additional health-related laws or rules; however, they cannot permit actions that are prohibited under the Criminal Code. If these rules are within provincial power, they may address health and other aspects of MAID, such as:
- the use of specific forms to fill out
- special medical training for providers of the service
- how information and data on the service are provided
- rules or requirements for either type of MAID
If you have questions about the law and policies in your specific location, contact your province or territory. Policies and procedures for medical assistance in dying may vary among provinces and territories. For example, Québec’s law permits only physicians to administer MAID. Québec also does not allow MAID through self-administration.
Monitoring and reporting on medical assistance in dying
Monitoring and reporting are critical components in building transparency and public trust in the law. They also help to reflect the seriousness of medical assistance in dying as an exception to the criminal laws that prohibit ending a human life.
According to the law, the Minister of Health must:
- publish guidelines on what information to include on death certificates in cases of medical assistance in dying
- make regulations to collect information, including information about race, Indigenous identity and disability
- publicly report on medical assistance in dying in Canada, including on forms of inequality and disadvantage that may be present
- must, when appropriate, consult with the minister responsible for the status of persons with disabilities in amending the regulations
Public reports can give a clear picture of how the legislation is working and help us to understand the impact of the legislation.
Regulations for the monitoring of medical assistance in dying
On August 8, 2018, the Government of Canada published regulations to create a federal, pan-Canadian monitoring system on medical assistance in dying.
The Regulations for the Monitoring of Medical Assistance in Dying came into force November 1, 2018.
Learn more about the:
On March 17, 2021, the Government announced changes to the law which came into effect immediately. This includes changes to the framework for collection of data on MAID in Canada.
Health Canada is in the process of amending the current Regulations to align with these recent legislative changes. The amended Regulations will improve data collection and reporting through the federal MAID monitoring regime and enhance the federal government’s ability to provide Canadians with a more comprehensive and inclusive picture about persons that request and receive MAID.
The revised Regulations are expected to come into effect on January 1, 2023. Until that time, health care providers should consult with their professional regulatory bodies to learn about any changes to their reporting obligations for MAID.
Annual reports on medical assistance in dying in Canada
Regulations require that the Minister of Health publish a report at least once a year using the information collected under the federal MAID monitoring system.
The reports provide information on:
- who is requesting MAID
- why MAID is requested
- circumstances when MAID is provided or when it is not provided
When the amended Regulations come into force, the expanded data collection requirements will begin for the 2023 calendar year. Data collected as a result of these new requirements will be reflected in the federal annual report on MAID in Canada for 2023, to be released in the summer of 2024.
- First Annual Report on Medical Assistance in Dying (MAID) in Canada, 2019
- Second Annual Report on Medical Assistance in Dying (MAID) in Canada, 2020
- Third Annual Report on Medical Assistance in Dying (MAID) in Canada, 2021
Interim reports on MAID in Canada:
Federal, provincial and territorial governments recognized the importance of the timely release of accurate information and collaborated to produce a series of interim reports about medical assistance in dying until the regulations were established in 2018.
The first interim report was released on April 26, 2017 and covered the first 6 months that MAID was available in Canada (June 17, 2016 to December 31, 2016). Three additional interim reports were produced, with the fourth being the final report under this interim reporting protocol.
- Report #1, issued on: April 26, 2017 (Interim update on medical assistance in dying in Canada June 17 to December 31, 2016)
- Report #2, issued on: October 6, 2017 (2nd Interim Report on Medical Assistance in Dying in Canada)
- Report #3, issued on: June 21, 2018 (3rd Interim Report on Medical Assistance in Dying in Canada)
- Report #4 – issued on: April 25, 2019 (4th Interim Report on Medical Assistance in Dying in Canada)
Parliamentary Review of Canada’s MAID law
As mandated in the revised MAID legislation, passed in March 2021, a Special Joint Committee on Medical Assistance in Dying has been appointed to undertake a review the provisions of the Criminal Code relating to MAID and their application, including but not limited to issues relating to mature minors, advance requests, mental illness, the state of palliative care in Canada and the protection of Canadians with disabilities. The Committee is expected to conclude its review within a year and present its report to Parliament.
Expert Panel on MAID and Mental Illness
As required by the recently amended framework for MAID in Canada, the Government of Canada established an Expert Panel on MAID and Mental Illness tasked with making recommendations on protocols, guidance and safeguards to apply to requests for MAID by persons who have a mental illness. This work will help ensure that practitioners are equipped to assess these requests in a safe and compassionate way based on rigorous clinical standards and legally mandated safeguards that are applied consistently across Canada.
On May 13, 2022, the Ministers of Health, and Justice, with the support of the Minister of Mental Health and Addictions and Associate Minister of Health, tabled the final report of the Expert Panel on MAID and Mental Illness in Parliament.
The findings will assist the Government in developing its approach for safely providing access to MAID for persons with a mental illness. Health professional regulatory bodies and associations who are already considering new guidance and resources for their members in anticipation of MAID eligibility for persons with a mental illness by March 17, 2023 will also benefit from the Expert Panel’s advice and recommendations.
Council of Canadian Academies
On December 13, 2016, the Government engaged the Council of Canadian Academies (CCA) to conduct independent reviews related to specific types of requests for medical assistance in dying – requests by mature minors, advance requests, and requests where a mental disorder is the sole underlying medical condition. These issues were the subject of debate when Bill C-14, the Government’s legislation on medical assistance in dying, was being considered by Parliament. The Act required the Ministers of Health and Justice to initiate independent reviews on the three issues and table reports in Parliament within 2 years of initiation.
The purpose of the reviews was to gather and analyze relevant information and evidence on the diverse perspectives and issues surrounding requests for medical assistance in dying in the three areas, in order to facilitate an informed, evidence-based, dialogue among Canadians and decision-makers.
The CCA reviews were led by a multidisciplinary panel of 43 experts who reviewed an extensive body of evidence including Canadian and international academic and policy research, written submissions from organizations affected by, or involved in, assisted dying, and conversations with Indigenous Elders. The reviews do not include recommendations, as is the practice with every CCA report, but synthesize the body of evidence.
Supporting access to a range of care and support options
We strongly support better access and availability of care options for all Canadians.
To better meet the palliative and end-of-life care needs of Canadians, we are committed to:
- providing investments for better home care, including palliative care
- supporting the provinces and territories to improve access to home and palliative care services through bilateral agreements in support of a Common Statement of Principles on Shared Health Priorities
- overseeing and coordinating the implementation of the Action Plan on Palliative Care, which lays out our five-year plan to tackle issues identified in the Framework on Palliative Care in Canada
- Palliative care
- Options and decision making at the end of life
- Contact Information and Links for End-of-Life Care Services
To better meet the needs of disability communities in Canada, we are committed to:
- implementing a Disability Inclusion Action Plan which will include:
- a Canada Disability Benefit modelled after the Guaranteed Income Supplement
- a robust employment strategy
- a better process to determine eligibility for government disability programs and benefits
Learn more about benefits and supports for persons with disabilities in Canada:
To better meet the mental health needs of Canadians, we are committed to:
- supporting the provinces and territories to improve access to mental health and addiction services as part of the Common Statement of Principles on Shared Health Priorities.
- Developing mental health and substance use standards to formalize what Canadians can reasonably expect in terms of the services available to them, including timeliness, consistency and quality.
- making investments in the Centre for Addiction and Mental Health to implement and sustain an operational pan-Canadian suicide prevention service in partnership with the Canadian Mental Health Association and Crisis Services Canada.
- making significant investments to support Canadians during the COVID-19 pandemic, including:
- the Safe Restart Agreement to address immediate mental health and substance use needs and gaps.
- mental health and virtual supports to bolster distress centres.
- the launch of Wellness Together Canada portal, providing Canadians with access to services across the continuum of care, from self-guided resources to live coaching, peer support and counselling that are appropriate to the users’ needs.
- the launch of PocketWell, a downloadable companion app to the Wellness Together Canada portal which offers users the opportunity to assess their mood and well-being and to directly link to resources and services offered on the online portal.
We also are making additional efforts and investments aimed to:
- strengthen protective factors that lead to positive mental health
- reduce and address the risk factors that can lead to mental illness and suicide
- reduce the stigma and discrimination attached to poor mental health, mental illness and problematic substance use