Contemporary request and advance request for medical assistance in dying: what are the differences?

Until October 30, 2024, these individuals had only one option for obtaining medical assistance in dying: the contemporary request. This is the most well-known type of request and can also be made by individuals suffering from other serious and incurable health conditions that do not result in incapacity to consent to care.

Since October 30, 2024, a new option has been available to people with serious and incurable illness in Quebec: the advance request for medical assistance in dying.

Contemporary request
It is not necessary to have reached a certain stage in the illness to submit a contemporary request for medical assistance in dying following a diagnosis of serious and incurable illness. The contemporary request is assessed based on the person’s personal assessment of their suffering and decline associated with their illness. Physical and/or psychological suffering may motivate the request. In the case of psychological suffering, loss of ability to perform daily activities, a sense of loss of dignity, and a feeling of isolation are commonly noted. The person is free to make such a request at any time following their diagnosis, as long as they are capable cognitively of doing so. When making their request, they also do not have to determine in advance exactly when they would like to receive care.

Learn more about contemporary requests.

Advance Request
Similarly, a person can also complete an advance request at any time following a diagnosis of serious and incurable illness, as long as they are capable of doing so. However, medical assistance in dying can only be provided afterward when the person has become incapacitated and exhibits certain previously identified clinical manifestations.

Learn more about the advance request for medical assistance in dying

Each request is made using a dedicated form, which is completed by the individual themselves. The form is a key element of the process: it formalizes the request.
The two requests are not made using the same form.

Contemporary Application
The contemporary application form must be completed and signed by any healthcare professional chosen by the individual (not necessarily a physician) and in the presence of an independent and validly recognized witness. The healthcare professional then forwards the completed and signed form to the appropriate authorities.

Advance Request
The advance request form must be completed online and signed in the presence of a physician or a SNP, two witnesses (unless the request is made by notarial deed), and one or more trusted third parties, if any. The completed and signed online form is sent by the healthcare professional to a government registry designated for this purpose.

At the time of completing the request (form)
The person must still be capable at the time of completing their request, whether it is contemporary or anticipated. No one else may complete and sign the form in their place.

At the time of the request’s assessment
When a contemporary request is assessed, the person is still capable of consenting to care: this is, in fact, a necessary condition for such a request to be accepted.

However, in the case of an anticipated request, the person has become incapable of consenting by the time their request is assessed. It may have been submitted months or years earlier. This is the very basis of the principle of an anticipated request: a request is completed while still capable, knowing that they will no longer be capable of consenting to care at the time the request is assessed.

In a contemporary request
The two physicians or SPNs assessing the request repeatedly ensure the person’s consent during the discussions surrounding their assessment. Since the person still possesses capacity, their verbal consent is valid.

With an advance request
The person is no longer capable of providing consent to care when their request is assessed. Therefore, the person must describe, in the advance request form, the clinical manifestations of their illness that will be considered, once they become incapable of consenting to care, as an expression of their consent to receive medical assistance in dying.

Thus, when the person who has become incapacitated presents these clinical manifestations recurrently, the competent professionals will consider that the person consents to medical assistance in dying. These clinical manifestations are therefore absolutely necessary conditions for offering medical assistance in dying following an advance request. That said, it is not, in itself, a sufficient condition for obtaining the care.

For a request to be accepted, whether contemporary or anticipated, the law requires that a condition of persistent and unbearable suffering be met.

In a contemporary request
The person who is still capable is actively involved in the assessment of their request. They can therefore describe their suffering themselves. The assessing physicians or SNPs must ensure that the criteria required by law are met by holding several discussions with the person and their healthcare team regarding their prognosis, wishes, and suffering.

In the advance request
The person is no longer able to actively participate in such discussions at the time their request is being assessed. The assessing physicians or SNPs are therefore the sole judges of the conditions required by law and the person’s suffering.

However, this aspect involves a degree of subjectivity: different assessing physicians or SNPs faced with the same clinical situation may have different opinions about the apparent and hidden suffering experienced by the person.

What is particularly challenging is that many incapacitated patients living with a serious and incurable illness, even at an advanced stage, do not necessarily present apparent suffering. If the person progresses to such a state of dementia with unobservable suffering, it is possible that an assessing physician or SNP refuses the request as long as the person remains in this state, even if the clinical manifestations provided for in the form have been achieved.

Please note that if the evaluating physicians or SNPs determine that all the legal requirements are not met at a certain point, the advance request assessment may be repeated at a later date. A new review will then be conducted, as the health status of the person with a serious and incurable illness is evolving. The advance request has no deadline.

Trusted third parties previously designated at the time the application was completed may participate in the assessment; however, they do not determine the outcome.

For a contemporary request
The evaluation by the first evaluating physician or SNP normally takes place within a few weeks of the request being submitted. A 90-day reflection period then applies if the evaluating physician or SNP judges that natural death is not reasonably foreseeable. Once the request has been approved by both evaluating physicians or SNP, the time between this approval and the actual treatment is at the discretion of the person. The person can determine the timing of medical assistance in dying, as long as they are still capable of consenting. A waiver of final consent form is also available if the person fears losing their incapacity before receiving the treatment (for example, due to medication use). Although there is no theoretically maximum possible delay between the acceptance of the request and obtaining care, this delay must be reasonable in the eyes of many practitioners: if the request is made in order to obtain care much later, some evaluating professionals may conclude that the current suffering is probably not intolerable and ask the person to resubmit their request at a later date. In practice, the delay between the approval of the request and the provision of care typically varies from a few hours to a few months.

For advance request
The time between the writing of the request and its assessment is unpredictable, because a serious and incurable illness evolves over a long period and at a variable pace. The person, becoming incapacitated over the course of this evolution, will not be able to choose for themselves when their request will be assessed, nor when medical assistance in dying will be offered to them if their request is approved. The trusted third parties designated when the advance request is written can request an assessment and notify the care team when the clinical manifestations anticipated in the request are reached.

Following a diagnosis of a serious and incurable illness, a person wishing to obtain medical assistance in dying can submit a contemporaneous request and/or an advance request.

An advance request allows the person to prolong their life beyond their loss of capacity while taking into account their desire to preserve their dignity. In doing so, it requires the person to rely on professional assessors to determine if and when medical assistance in dying will be offered, without them being able to actively participate in these decisions at the time they are made.

A contemporaneous request allows the person to actively participate in the assessment process, including describing their suffering at the time it is assessed. Since they are not experiencing the loss of capacity caused by the illness, the person can, if their request is approved, determine when they will receive medical assistance in dying, as long as they are still capable of doing so. However, this implies that the person forgoes moments of life that could have been lived despite the loss of capacity.

If you would like additional information on both types of requests, do not hesitate to contact the Association Québécoise du droit de mourir dans  la dignité (AQDMD). You can also discuss this with your doctor and/or seek the support of a social worker to help you make the best decision for you.