Medical Assistance in Dying
Can an RN or RPN pronounce death when death has occurred?
There is no legal requirement that would prevent an RN or RPN from pronouncing death; however, there is a distinction between pronouncing death and certifying death.
The Practice Standard: Decisions About Procedures and Authority outlines the considerations and accountabilities when performing any procedure. In addition, you should consider if there are specific organizational policies and procedures regarding who may pronounce death where you work.
If a client has asked a nurse for assistance in self-administering a medication to end life, are there any restrictions on how I can assist the client?
RNs and RPNs are not authorized to administer a medication to end life.
If a nurse is assisting the client to self-administer a medication that has been prescribed for them for the purpose of medical assistance in dying, they should exercise extreme caution. The decision and action of taking the medication to end life must be the client’s own.
The federal government has provided the following guidance (Legislative Background: Medical Assistance in Dying (Bill C-14)) with respect to acceptable forms of assistance: “A client may still need various forms of assistance depending on their state of health. For instance, they may need someone to open the bottle that contains such medication, or to lift a glass of water to their mouth so that they can swallow it.”
Is an RN or RPN accountable for confirming legal requirements have been met before assisting with medical assistance in dying?
RNs and RPNs are not responsible for assessing whether a patient meets eligibility criteria, or documenting or collecting a patient’s consent or written request for medical assistance in dying. The NP or physician providing care to the patient is responsible for ensuring that the patient’s written request meets legal requirements, and documenting the patient’s initial and final consent prior to administering medical assistance in dying.
The RN and RPN should be confident that the NP or physician has affirmed that each of the eligibility criteria and safeguards are met. The RN and RPN does not need to confirm the specific details of how the assessment was conducted or documented. Where an NP or physician has not indicated that all criteria and safeguards have been met, the RN or RPN should follow-up with the NP or physician.
*This response was extracted from the Ontario College of Pharmacists’ Medical Assistance in Dying – Guidance to Pharmacists and Pharmacy Technicians on July 14, 2016, and could change from time to time.
My client has decided to stop treatment. Does this mean that the client is now participating in medical assistance in dying?
No. A client’s choice to stop treatment or refuse new treatment is not the same as medical assistance in dying. Medical assistance in dying, as defined in the Criminal Code, only refers to when:
- an NP or physician provides assistance by administering a medication to a client, at their request, that causes their death (i.e., clinician-assisted medical assistance in dying ); or
- an NP or physician prescribes or provides a medication to a client, at their request, so that they may self-administer the medication and in doing so cause their own death (i.e., client self-administered medical assistance in dying)
What are the professional liability protection needs for nurses involved in medical assistance in dying?
All nurses are required to have professional liability protection (PLP).
CNO has no additional liability protection requirements for a nurse who is involved in medical assistance in dying. It may be prudent to contact your PLP provider to discuss with them if it would be beneficial for you to have additional coverage.
My client has asked me to be an independent witness, can I do this?
No. The law requires that witnesses must not be directly involved in providing health care services or personal care to the client.
In addition, witnesses must not:
- know or believe that they are a beneficiary of the client (e.g. within the client’s will)
- know or believe that they are a recipient, in any other way, of a financial or other material benefit resulting from the client’s death; and
- be an owner or operator of a health care facility where the client is being treated, or any facility in which the client resides
Can a nurse sign a client's request for medical assistance in dying on their behalf?
Yes, a nurse can sign a request for medical assistance in dying on the client’s behalf if the nurse meets the legal requirement to do so.
The law requires the client to make a written request for medical assistance in dying. The request must be signed and dated by the client after they have been informed by a physician or NP that they have a grievous and irremediable medical condition. If the client is unable to sign and date the request, another individual may do so in the client’s presence and under the client’s express direction.
The person who signs on the client’s behalf must:
- be at least 18 years of age
- understand the nature of the request for medical assistance in dying
- not know or believe that they are a beneficiary under the client’s will; and
- not know or believe that they are a recipient, in any other way, of a financial or other material benefit resulting from the client’s death
Can an RN or RPN obtain consent for medical assistance in dying?
No. Consent for medical assistance in dying must be obtained by the NP or physician who is authorizing the procedure.
What should a nurse do with unused medication after a client has received medical assistance in dying?
Nurses should collaborate with the health care team to determine the appropriate strategy for disposal of unused medications when medical assistance in dying has been completed. The Ontario College of Pharmacists states, “Pharmacists are also encouraged to discuss appropriate disposal of unused medications with the patient or his/her agent.” For additional information, please refer the Practice Standard Medication and to Ontario College of Pharmacists’ Medical Assistance in Dying – Guidance to Pharmacists and Pharmacy Technicians .
My client wishes to use an advance directive for medical assistance in dying. Can I accept this directive?
No. The law does not allow advance directives for medical assistance in dying.
Can the substitute decision maker (SDM) authorize medical assistance in dying?
No. The legislation clearly identifies that the person themselves must be capable of making the request and providing informed consent immediately before providing the medical assistance in dying. Therefore, there is no role for the SDM in medical assistance in dying.
Since NPs in Ontario are not authorized to prescribe controlled substances, can NPs administer medication(s) prescribed by a physician for medical assistance in dying?
This question is not answered in the law. However it appears that the intent of the law is that the clinician who prescribes the medication for clinician-assisted medical assistance in dying is also accountable for administering the medication. Therefore, it would be prudent for the NP to refrain from administering medication prescribed by another clinician for the purposes of medical assistance in dying.
I have assessed a client to be eligible for medical assistance in dying. The client is deteriorating, and I am concerned that he may lose capacity to provide consent before the 10-day waiting period is over. What do I need to do to reduce the waiting period in this situation?
If it is your professional opinion that the client cannot maintain capacity for the 10-day waiting period you should discuss your concern, including your clinical reasoning, with the client and the NP or physician who is providing a second opinion about the client’s eligibility.
The law allows the 10-day period to be shortened only if both you and the second NP or physician are of the opinion that the person’s death, or the loss of their capacity to provide informed consent, is imminent. You may then shorten the waiting period to what you consider to be appropriate in the circumstance.
The law requires you to inform the pharmacist when a prescription is for medication that will be used for medical assistance in dying. In all medical assistance in dying cases, contact the pharmacist as soon as possible after you have determined the client’s eligibility. In this case, inform the pharmacist that you are discussing the possibility of shortening the 10-day waiting period. This assists the pharmacy in ensuring they have the necessary medications in-stock, which enables timely access to care for clients.
I have determined a client meets the eligibility criteria for medical assistance in dying. The second NP or physician has concluded the client does not meet the eligibility criteria. What should I do?
This second confirmation is a legal requirement. You must not provide medical assistance in dying if the second NP or physician concludes that the client is not eligible. Clients should be prepared for the possibility that even if you consider them to be eligible, the NP or physician who provides a second opinion may not agree. If the second NP or physician concludes that the client does not meet eligibility criteria, you should inform the client that you cannot proceed.
My client has requested medical assistance in dying but I do not provide this service in my practice. I understand I am obligated to refer them to another NP or physician who is able to provide medical assistance in dying. How can I find an alternate provider?
You should first speak to other NPs or physicians in your professional network to see if there is someone who provides this service. If you are not able to find someone, ask your employer about whether your organization has any existing networks. Finally, the Ministry of Health and Long-Term Care (MOHLTC) is offering a referral service. This service is an option for you if you have not been able to find an NP or physician who can provide medical assistance in dying through the first two strategies.
NPs and physicians seeking assistance in making a referral for an initial assessment or for a second opinion can call the MOHLTC toll-free number at: 1-844-243-5880.
The phone line will be answered during regular business hours. There is a voicemail option available, where you will be prompted to leave a message including your name, contact information and practice location postal code. This voicemail box is monitored during regular business hours. No client information should be provided to the MOHLTC.
How do I identify myself as a professional willing to provide medical assistance in dying to clients?
If you wish to register yourself as a clinician willing to provide aspects of medical assistance in dying to clients, please contact the MOHLTC at MAIDregistration@ontario.ca. Your contact information will be used on the MOHLTC’s service for clinicians seeking referral supports on behalf of clients requesting medical assistance in dying.
Before registering yourself as a clinician with the referral service, you may wish to consult with your employer to determine whether the aspects of medical assistance in dying services that you are willing to provide are included in your role.
MOHLTC’s referral service is for NPs and physicians seeking assistance in making a referral for an initial assessment or for a second opinion. It is not mandatory for clinicians to use this service, but is an option if an NP or physician is not able to find another clinician through their own professional networks or through their organization.