The answers are for Quebec (Act 2); however, the federal law (C-14) applies throughout Canada and in part in Quebec, but not in all aspects. Therefore, there may be differences between Canada and Quebec.
Can I change my mind after my request has been accepted?
Is it possible to postpone my request once the date has been set?
Yes. You can postpone the date upon which MAID will be administered, at any time. There is no time limit set for receiving MAID, as long as eligibility criteria are still met, especially regarding the capacity to consent, which must be clear until the very last minute.
Can I change my mind during the process if I no longer wish to receive MAID?
Yes. You can withdraw your request at any time, up to the very last moment before MAID is administered. In fact, the physician administering MAID is required to ask you this immediately before proceeding.
COVID-19 and medical assistance in dying (MAID)
Can family members or loved ones visit a patient who is nearing the end of their life or who will be receiving MAID?
As of August 2021, most restrictions have been lifted for patients in their end of life in all establishments, except in some nursing homes or CHSLDs.
You will need to refer to the institution to find out what their rules are, but in general, family members are admitted so they can be with their relatives. Obviously, this must be done according to health measures, and it is much easier if all parties have been vaccinated.
Do I have to pay for MAID?
How much does a citizen insured by the Régie de l’assurance maladie du Québec (RAMQ) have to pay to receive MAID?
Any person insured according to the Quebec Health Insurance Act will have nothing to pay since all costs are covered. In fact, to “be insured” according to the law is the first eligibility criterion for MAID, which prevents medical tourism for MAID.
How does one request MAID?
My loved one is unable to consent to receiving MAID. Can I provide consent for them?
No. The patient must be the one consenting to MAID, on at least two (2) occasions: at the time of the request and immediately before receiving MAID.
However, according to federal law (Criminal Code), a patient who is deemed to have a reasonably foreseeable natural death and who is able to request MAID may, with the agreement of the physician who will perform MAID, sign a document stating that if he or she loses their decision-making capacity, the medical practitioner will still be allowed to proceed. This is called the “waiver of final consent.”
As an example, this arrangement allows a patient who is experiencing severe pain to continue taking their medication even if this might limit, in part, their capacity to consent. The same is true of a patient who has fallen into a mild coma caused by their condition. The physician will still be able to administer MAID, after having informed the patient’s loved ones regarding the waiver of final consent.
Advance requests—Before reaching your end of life
The “end of life” criterion is no longer an eligibility requirement, which is also the case for the “reasonably foreseeable natural death” criterion.
From the moment you are diagnosed with a physical illness that is deemed incurable or for which you do not want treatment, it is your right to request MAID. Together, you and the physician performing the assessment will select the date that MAID will be administered.
Advance requests—Degenerative diseases
If the physician performing the assessment has determined that death is reasonably foreseeable, the patient will be eligible for MAID.
If a person has been diagnosed with a physical degenerative disease and has the capacity to consent, but death is not reasonably foreseeable (short- and medium-term prognosis), this person can request MAID and receive it when they are ready. This would include, for instance, a multiple sclerosis diagnosis.
If a person has been diagnosed with a cognitive neurodegenerative disease like Alzheimer’s disease, they will be eligible for MAID as long as they have decision-making capacity. However, they will not be able to receive MAID if they have become incapacitated, even if they prepared an advance request.
Can a loved one make the request for me if I am unable to do so?
No. All persons seeking MAID must make the request themselves.
If a person requesting MAID cannot sign and date the form because they cannot write or because they are physically incapable of doing so, a third party can sign the document, in the presence of the applicant and according to certain guidelines. However, all eligibility criteria must, of course, be met, especially regarding the ability to understand what medical assistance in dying means. Moreover, the physician receiving the request will have to verify this by following a well-defined protocol.
Where can I find the Request for medical aid in dying form from the Quebec ministère de la Santé et des Services sociaux?
How is MAID administered?
What does the term “independent physicians” mean?
The Criminal Code specifies that, in the context of a MAID request, the medical practitioner providing MAID and the medical practitioner providing the opinion are independent if they:
- are not a mentor to the other practitioner or responsible for supervising their work;
- do not 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, other than standard compensation for their services relating to the request; and
- do not know or believe that they are connected to the other practitioner or to the person making the request in any other way that would affect their objectivity.
The physician who assesses the patient, in a hospital, for instance, may be accompanied by their resident or a physician in training for MAID. What matters is that the physician providing the second opinion is independent of the first within the wording of the Criminal Code. Furthermore, it is important to specify that the opinion of the second physician must be objective and impartial and must not be influenced by his or her personal convictions. “A doctor whose personal convictions of a moral or religious nature prevent them from participating in the MAID process should refrain from participating in this second consultation.”
– Guide d’exercice et lignes directrices pharmacologiques, Collège des médecins du Québec, updated in November 2017.
How long is the process of administering MAID?
The procedure itself can take 20 to 30 minutes. From the time of the first injection, MAID usually takes between 5 and 10 minutes.
Can the two physicians involved in a MAID case know each other?
Yes, of course, because in most circles, physicians do know each other. It is important, however, that they be independent of each other within the meaning of the law and “with respect to the person applying for MAID (Article 29 (3) of the LCSFV; section 242.2 (3) (e) and (f) of the Criminal Code). It is critical to avoid situations that could influence and bias their professional judgment.”
– Guide d’exercice et lignes directrices pharmacologiques, Collège des médecins du Québec, updated in November 2017.
Who can be present while MAID is being administered? https://aqdmd.org/wp-admin/edit.php?post_type=faq
The applicant gets to decide who they want by their side at the time of their death. “Depending on the patient and what MAID means to them, the moment at which MAID is administered can be experienced between only the patient and the doctor, or it can be a shared event: if this is the patient’s wish, relatives can be present when MAID is administered, if they wish to attend. Furthermore, in accordance with the wishes of the patient, a nurse, and other members of the interdisciplinary team, or even another physician, may be present.”
– Guide d’exercice et lignes directrices pharmacologiques, Collège des médecins du Québec, updated in November 2017.
Can I receive MAID if I am in a palliative care facility?
As of August 2021, more than half of palliative care homes in Quebec now provide MAID.
The AQDMD is actively lobbying for all palliative care facilities to provide MAID because they are heavily subsidized by the government of Quebec, which, in a way, makes them public institutions.
Note that in most of these facilities, the patient must first be admitted to receive palliative care. Subsequently, they can put in a request for MAID if they wish to do so and if they meet all legal criteria.
Palliative care homes offering MAID:
- Boucherville: Maison de soins palliatifs Source Bleue
- Bromont: La Maison Au Diapason
- Drummondville: Maison René-Verrier
- Jonquière: La Maison de soins palliatifs du Saguenay
- Lac-Mégantic: Maison La Cinquième Saison
- Lévis: Maison de soins palliatifs du Littoral
- Montmagny: Maison d’Hélène
- Quebec City: Maison Michel-Sarrazin
- Rivière-du-Loup: Maison Desjardins de soins palliatifs du KRTB
- Roberval: Le Havre du Lac St-Jean
- Rouyn-Noranda: Maison de L’Envol
- Saint-Jérôme: Pallia-Vie, Maison de soins palliatifs de la Rivière-du-Nord
- Sept-Îles: Maison L’Élyme des Sables
- Shawinigan: Maison Aline Chrétien
- Sherbrooke: Maison Aube-Lumière
- Terrebonne: Maison Adhémar-Dion
- Trois-Rivières: Maison Albatros
- Val-D’Or: Maison de la Source Gabriel
Where is MAID administered?
MAID may be administered in a healthcare facility or in a patient’s home. The choice comes down to the patient.
Who can administer MAID?
In Quebec, only physicians can administer MAID. In the other provinces, according to federal Bill C-14, nurse practitioners may also administer MAID.
Medical assistance in dying (MAID)
In the event of a serious illness that would cause me to suffer, I would like to take a pill myself to end my life without pain. How do I get this pill if and when the time comes?
You cannot do this in Quebec, where self-administered MAID is not legal. It is allowed, however, in the rest of Canada.
In Quebec, in the event of a serious illness, you can request and receive MAID with complete peace of mind if you meet the legal criteria. It will be administered by a physician.
In Canada, outside of Quebec, a physician or nurse practitioner can administer MAID to you. A physician can also prescribe medication that you would take in front of him or her.
Why is MAID chosen when palliative care is still an option?
In some cases, palliative care and other therapeutic means may fail to alleviate the patient’s suffering. In these circumstances, MAID becomes an option. MAID and palliative care are in no way contradictory. Instead, MAID is one of the healthcare options provided within a palliative spectrum.
Since when has MAID been legal in Quebec and Canada?
MAID has been legal in Quebec since Act 2 was passed on June 5, 2014, and came into effect on December 20, 2015. It has been legal in Canada since Bill C-14 was passed to amend the Criminal Code, on June 17, 2016.
What is the difference between MAID and assisted suicide?
Two kinds of MAID are permitted in Canada, outside of Quebec. The first is when a physician or nurse practitioner directly administers a substance that causes the death of the person who has requested it (“medical assistance in dying”). The second is when a physician or nurse practitioner gives or prescribes to a patient a substance that the patient can self-administer to cause their own death (“self-administered medical assistance in dying,” sometimes referred to as “assisted suicide”). NB: it is worth noting that the latter term, “assisted suicide,” is a stigmatizing expression that should be avoided.
In Quebec, only a physician can administer medication and cannot, under any circumstances, delegate this act to another person, whether they are a resident or a nurse.
Self-administered MAID is illegal in Quebec, but is legal in the rest of Canada.
What is MAID?
MAID stands for “medical assistance in dying” or “medical aid in dying,” which are both the same thing. This is a procedure governed by rigorous criteria outlined in both provincial and federal law.
During the MAID procedure, the physician administers substances that will cause the death of a patient who is suffering from a grievous and incurable illness that has become intolerable to them, thus putting an end to their physical or psychological suffering. The law offers each person the opportunity to decide how they want their end-of-life to be, in accordance with their values and their dignity.
What is the state of MAID today, after the September 11, 2019, judgment rendered by Justice Beaudoin of the Superior Court of Quebec?
The September 11, 2019, judgment rendered by Justice Baudouin of the Superior Court of Quebec states that both the “end of life” term used in Quebec law and the “reasonably foreseeable natural death” term listed in criteria for access to MAID are unconstitutional, due to the Supreme Court judgment made February 6, 2015.
Since then and since the March 17, 2021, Criminal Code amendment, the conditions are as follows:
- All criteria under Quebec law have remained the same, except the one requiring that a patient be in their end of life, which is no longer operational.
- As for the (federal) Criminal Code, “reasonably foreseeable natural death” is no longer an eligibility criterion for MAID but has become a safeguard measure to separate patients into two categories:
- Persons whose natural death is reasonably foreseeable, like a patient with metastatic cancer.
- Persons whose death is not reasonably foreseeable (over time), given their illness. This includes, for instance, patients with a degenerative neurological disease like multiple sclerosis, where natural death is not reasonably foreseeable (short- or medium-term prognosis), but it is known that the illness will lead to the patient’s death. Once again, this is no longer an eligibility criterion but rather a safeguard meant to differentiate patients.
In a nutshell, a patient requesting MAID must meet all other legal criteria but does not need to be at the end of their life. Furthermore, neither Quebec law nor federal law specify a time limit. For instance, a patient with advanced rheumatoid arthritis that will not cause their death within the next two to five years might still be eligible for MAID if all other criteria are met.
Support and the role of loved ones
What kind of support can a MAID applicant receive during the process?
The applicant and their family can request psychological, social, and spiritual support if they wish to do so.
Will the applicant’s family be consulted when making the decision?
No. The decision is made only by the applicant and only he or she can decide whether to inform or consult family members.
Would a close family member, such as a spouse or a child, have the right to refuse access to MAID for their loved one?
No. Only the patient can make this decision. Physicians must make sure that loved ones receive the appropriate assistance and support both before and after MAID is administered.
What role does the family play in the process?
The family takes on a supportive role with their loved one throughout the process, from the application to MAID administration. The physician makes sure that loved ones receive the support and help they need throughout the process.
What are “advance medical directives,” and can I request MAID for a future date when I will need it?
Do I need to have my form signed or validated by a notary?
Only if you want to. You can choose to consult a notary who will record your wishes in a notarial deed, which presents the same content as the Advance Medical Directives form prescribed by the Ministry. At your request, the notary will send the notarial act to the RAMQ to have it filed in the Register for advance medical directives.
You can also send the form to your physician or a healthcare professional so that they can place it in your medical file. If applicable, tell your relatives where you filed your notarial deed.
The notary can check with you that no conflict exists between the wishes you expressed elsewhere and your advance medical directives. The notary can also answer your questions regarding legal matters.
The only important point is that you send the form to the government yourself so that your directives will be entered in the Register.
How do I get my form?
This is a form provided by the Government of Quebec. It must be filled out by you and signed by you and by two adult witnesses. This document is sent to the MSSS digital files, which are accessible everywhere in the network, therefore in all health establishments. The document is binding for all medical staff, which means they are required to abide by it.
To receive your personalized form, you have several choices:
Visit the RAMQ website.
Or type this into your search engine: Advance medical directives.
Or by phone:
- Quebec: 418-646-4636
- Montreal: 514-864-3411
- Elsewhere in Quebec: 1-800-561-9749
Before requesting your form from the Régie, we strongly recommend that you become fully informed about advance medical directives, by reading the Advance medical directives section of the Government of Quebec website.
Are clinicians (nurses and physicians) required to follow my advanced medical directives or do they decide whether I am capable of consent, for instance if I end up in a coma?
If you have filled out the official government form, this document will be submitted to the MSSS digital files, which are accessible across the network, therefore in all health establishments. The document is binding for all medical staff, which means they are required to abide by it.
According to section 58 of the same Act 2:
When a person is incapable of giving consent to care, clearly expressed instructions relating to care that are recorded in the advance medical directives register or filed in the person’s record carry, for all health professionals having access to the register or record, the same weight as wishes expressed by a person capable of giving consent to care.
What are “advance medical directives”?
Advance medical directives are written instructions, in which a person of full age and with the capacity to consent, states which medical care they accept or refuse to receive in the event that they lose the capacity to consent to care in certain specific clinical situations.
According to Act 2 on End-of-life care, section 51:
A person of full age who is capable of giving consent to care may, by means of advance medical directives, specify whether or not they consent to care that may be required by their state of health, in the event they become incapable of giving consent.
However, in such directives the person may not request medical aid in dying.
Therefore, under the law, it is not possible to request MAID in advance medical directives.
What are the criteria for requesting MAID?
Would a patient from another province have the right to receive MAID in Quebec?
The patient can receive MAID only if they are insured according to the Health Insurance Act and are registered with the Régie de l’assurance maladie du Québec (RAMQ).
Can a person with a mental illness have access to MAID?
Yes, but this person must meet all the eligibility criteria listed above. In other words, a person who has a physical illness that meets the criteria, in addition to a mental health problem, can access MAID as long as they have the capacity to consent.
However, a person suffering from only a mental illness, without another medical condition, will not be eligible for MAID until March 17, 2023, according to the Canadian Criminal Code. Legislation will need to be developed by this date, to address such requests.
What are the eligibility criteria?
Eligibility criteria for access to MAID in Quebec:
- The person is insured according to the Health Insurance Act;
- The person is at least 18 years of age and capable of giving consent to care;
- The person is suffering from a serious and incurable disease;
- The person’s medical condition is in an advanced state of irreversible decline in capability;
- The person is experiencing constant and unbearable physical or psychological suffering that cannot be relieved in a manner that they deem tolerable.
The Criminal Code of Canada, for its part, specifies that “a person has a grievous and irremediable medical condition only if they meet all of the following criteria:
- 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 that cannot be relieved under conditions that they consider acceptable.”
What does “free and informed consent” mean?
According to medical law, the MAID applicant must, at all times and during the entire process, be able to make a free and informed decision. However, a patient who does not have intellectual autonomy and for whom this is a lifelong condition, will never be able to request MAID. Why not?
Requesting MAID is a critical decision, one that cannot be undone once the process has been completed. To make a request, the patient must fully understand and make informed decisions regarding their health status and the care they need. In some circumstances, a patient with a mental illness may be eligible as long as they still have the capacity to consent. Eligibility is assessed by health professionals and a psychiatrist may be asked to give their opinion.
In such a context, it is obvious that a patient who does not have intellectual autonomy (due to a congenital condition or an acquired condition, like dementia) will never be able to request MAID.
How can we be sure that the patient is making the decision voluntarily, without being influenced by others?
The physician must verify that the patient has not been subjected to external pressure in their decision-making process. The physician will ask the patient several times if they still wish to continue with the process after having made the request. The physician must, of course, provide all information required so that the patient can make an informed decision. Moreover, the physician must ensure the applicant’s ability to fully understand the situation and will do so with available means like the “Nova Scotia Criteria.” The second physician must also confirm that the patient meets all MAID requirements. This ensures that the patient is making a decision out of their own free will, without outside influence.
What happens after a MAID recipient’s death?
Can a MAID recipient donate their organs?
Yes, and this is a very generous gesture. The patient can donate organs and tissue, but assessment of this request and medical decisions are made on a case-by-case basis and depend on multiple medical factors. Is there cancer? Has cancer metastasized? What is the state of organ function (liver, kidney, heart, etc.)?
This decision and the assessment must also be carried out several days before MAID is administered, so that required tests can be run to verify the donor’s overall physiological state.
It is important to know that to allow for an organ donation, MAID needs to be administered under special conditions, in the hospital, usually in an operating room. All personnel working in this room understand that they must give the patient’s loved ones the space that they need, so that the process can be carried out with tact, allowing loved ones to take their time. However, time spent with the deceased must be well regulated and quick, at the start of the procedure. All members of the medical and surgical team will be able to accompany you with the utmost respect.
What happens to the patient’s body after their death?
The patient is buried or cremated according to the wishes that they expressed in writing or verbally, to their loved ones.
What happens if my request is refused?
What happens when the person’s request is denied?
The physician informs the patient as to the reason their request was denied and records it in the patient’s file.
What are the limits that determine when a professional is allowed to say that they do not wish to participate in MAID?
No clear limit has been defined. Professionals can refuse to administer MAID or to participate in the MAID process according to their personal convictions. However, they must refer the patient to a professional who will be able to respond to their request.
Can a physician refuse to provide MAID for me?
If you meet the eligibility criteria, the physician who is in charge of your case and who does not want to provide this final treatment, for whatever reason, is within his or her rights. This person does, however, have an ethical obligation to refer you to another physician who will be ready to deal with your case.
According to the Collège des médecins du Québec, “the physician who receives a request for MAID is therefore required to respond to it with professionalism, whatever his or her personal convictions may be. However, under certain conditions, the physician is not required to participate in the MAID process if his or her personal convictions, of a moral or religious nature, prevent him or her from doing so. Whatever the physician’s decision may be, it must be recorded in the patient’s file.”
In accordance with the Code of ethics of physicians, a physician may refuse to administer MAID, but he or she must ensure the continuity of care provided to the patient. The physician must therefore immediately notify relevant authorities, who will be responsible for finding a physician willing to take on the application.
What is the process?
I submitted my request for MAID. How long do I have to wait to receive MAID?
There is no mandatory waiting period between requesting and receiving MAID.
If your case falls in category 1 under federal law, the “reasonably foreseeable natural death,” you may receive MAID from the day your request was made, as long as a second physician has also provided their opinion. There is no maximum waiting time.
If the physician performing the assessment deems your case to be within the scope of a “natural death that is not reasonably foreseeable,” a 90-day waiting period will apply between the time of the first assessment by a physician (whether it was made based on your records, online, or in person) and the time MAID will be administered. There is no maximum waiting time, but everything is dependent on whether the patient is able to reiterate their request for MAID and to understand it.
To summarize, if your case involves a natural death that is not reasonably foreseeable, you will be allowed to receive MAID starting from the 91st day, but will not be required to do so. You can get it six months later, if you want to; but, of course, you will still need to have the capacity to consent.
What does “two independent witnesses” mean?
Despite what is still stated on the form, the law now requires (since March 17, 2021) only one independent witness, who can be a paid professional who is a member of your healthcare team.
What is the application process for requesting MAID?
Applicants must get their form signed by a health professional that is a member of a professional order (physician, nurse, social worker).
Initially, you do not need to include the name of the physician who will administer MAID, unless the physician who signs your request has also agreed to administer MAID to you.
This person does not need to be your attending physician, though it is highly recommended. By signing your form, the health professional is not in any way committing to continuing with the process; he or she is, however, required to forward your request to the CIUSSS or the CISSS in your region.
Once the form has been received, the organization will forward your request to a person who will meet with you for an assessment, to see if you meet the eligibility criteria. This should normally be done within 1 to 2 weeks, at most, following your request.
If the physician performing the assessment has determined that you meet the eligibility criteria, a second physician will perform an assessment, in person or on file, and contact you by telephone.
What is the role of the pharmacist? What drugs are used?
Why does the pharmacist have to prepare two identical kits with the injection equipment and the medication needed for MAID?
The second kit is a back-up, to be used in the event of equipment failure, a handling error or, if necessary, to adjust the dosage of the medication.
The remaining medication, including the second kit, even if it has not been used, must be returned in full to the pharmacist and it will be destroyed according to standard techniques.
Since the pandemic, drug shortages have caused restrictions on certain medications. This, fortunately, helped to improve things in this regard and greatly reduce waste, without impacting quality of care. As a result, the 2nd kit is only prepared in standard packaging, without being opened or placed in a syringe, which makes it possible to save it for another procedure.
Is it possible to pick up the drugs used for MAID at a neighbourhood pharmacy?
Yes, physicians can pick up medication for MAID if it will be administered in the patient’s home. In general, however, given the type of medication used, it will most often be supplied by a hospital pharmacy. In all cases, the physician should discuss this with the pharmacist in person. Given the type of drugs to be used to perform MAID, a wait time should be expected between the time the physician makes the request for medication and the time it is delivered by the pharmacist.