Competencies and Objectives (1 competency)
Exercise professional judgment as it relates to the registered nurse’s role in medical assistance in dying (MAiD).
Objectives – the registered nurse will:
- Define the process of Medical Assistance in Dying (MAiD)
- Explain the RN role in assisting nurse practitioners or physicians in the provision of MAiD
- Identify statutory safeguards that must be met before an eligible client can receive MAiD
- Define the term conscientious objection as it relates to MAiD
Synopsis of Information
On June 17, 2016, the federal government enacted legislation regulating the provision of medical assistance in dying (MAiD). This was in response to the Supreme Court of Canada’s Carter decision delivered on February 6, 2015, which struck down the law prohibiting MAiD for Canadians who met certain conditions outlined by the court
Definition of MAiD
MAiD refers to the process where, at the client’s request, an NP or physician:
- Prescribes and administers a medication to the client that causes their death; or
- Prescribes or provides a medication to the client so that the client may self-administer the medication and in so doing cause their own death.
RN role in assisting in the provision of MAiD
Nurses continue to have a major role in assisting in the provision of MAiD. It is essential to recognize their accountabilities and limitations as it relates to various aspects of MAiD including counselling clients and families about MAiD, client eligibility, statutory safeguards, administration of medications, privacy and confidentiality, and documentation.
If a client asks about MAiD, you can explore reasons for the client’s request but do so in the context all other end of life care options, including palliative care. You may provide information and answer client questions about MAiD that is client centered and reflects the client’s values. You should promptly inform the client’s primary care provider and other appropriate members of the health care team of the client’s requests and document the encounter in the client’s record.
Nurses who are assisting in MAiD as a member of the health care team are not permitted to determine the client’s eligibility, as that role remains the responsibility of the providing NP/physician. However, before assuming any role in the process, you must
- discuss the client’s request for assisted dying with other members of the healthcare team,
- review the client record and
- review the client’s written request for assisted dying.
In addition, you must:
- follow employer/agency policy regarding your participation in MAiD
- raise your concerns with the health care team or your manager if you have reason to believe that the client does not meet eligibility criteria.
The Criminal Code sets out a number of safeguards that must be met before an eligible client can receive assistance in dying. As a health care professional assisting in MAiD, you should be aware of these safeguards as well as any additional safeguards outlined in employer or agency policy.
As with client eligibility concerns, if you know or reasonably believe that not all mandatory safeguards have been complied with, you must immediately discuss these issues with other health care team members or your manager.
The safeguards in section 241.2(3) of the Criminal Code include, but are not limited to, the following:
- The client’s request must be made in writing and signed and dated by the client
- The client’s request must be signed and dated before two independent witnesses
- Another NP or physician has provided a written opinion confirming that the client meets all of the eligibility criteria set out in section 241.2(1) of the Criminal Code
- There are at least 10 clear days between the day on which the request was signed by the client and the day on which MAiD is provided or – if both NPs and/or physicians assessing the eligibility criteria are of the opinion that the client’s death, or the loss of capacity to provide informed consent, is imminent – any shorter period that the first NP/physician considers appropriate in the circumstances
- Immediately before the provision of MAiD, the NP or physician must give the client an opportunity to withdraw their request and ensure that the client gives express consent to receive MAiD.
Administration of Medication
Nurses are not authorized to administer the medication that causes the client’s death under any circumstances, even if requested by the providing NP/physician and/or the client.
You may, however, assist in the administration of the medication, including engaging in the following activities, at the direction of the providing NP/physician, where the safeguards outlined above have been met:
- Insert an intravenous line that will later be used to administer the medication;
- Be present during the administration of the medication to provide holistic nursing interventions to meet the needs of the client and their family during the dying process;
- In the case of a client seeking to self-administer the medication, passing the oral medication to the client, so long as the client explicitly asks for your assistance. In this scenario, you should refrain from activities that may be viewed as the actual administration of the medication, such as placing oral medication in the client’s mouth or pushing medication into the client’s intravenous line.
- As per the College Medication Guidelines, medications should be administered only by the health care professional who has prepared them except in the case of emergencies. Therefore, you should not prepare MAiD medications, such as drawing medication into a syringe, for the NP or physician who will be providing MAiD.
As with all other aspects of nursing practice, you must maintain the privacy and confidentiality of clients and families who are involved in MAiD.
When documenting discussions regarding MAiD or the care you provided with assisting with MAiD, you must follow agency policy and applicable documentation guidelines. Your documentation must be clear and comprehensive and, in addition, should include the identity of the persons present and the name of the provider that administers the medication, where applicable.
Witnessing a Written Request for MAiD
A client who wishes to receive assistance in dying must submit a request to the providing NP or physician. The request must be written, signed and dated by the client after they have been informed of or diagnosed with the grievous and irremediable medical condition.
The client may ask you to act as a witness to their signature on their written request for MAiD. You may act as a witness as long as you:
- are aware that the document is a formal request for assisted dying;
- are not directly involved with providing health care services or personal care services to the client making the request;
- do not directly provide personal care to the client;
- are not or reasonably believe that you are not a beneficiary under the client’s will or will receive a financial or other material benefit from the client’s death; are not an owner or operator of a health care facility where the client is being treated or any facility in which the client resides.
NOTE: Nurses must always follow agency policy to determine if they are permitted to witness the signature of a client requesting MAiD.
If MAiD is in conflict with your moral beliefs and values, you may decline to participate in any aspect of client care connected with it. However, if you choose not to participate on these grounds, you must promptly inform your employer of your objection (or your client if you are a self-employed nurse). You must continue to provide safe, competent, ethical and compassionate care until alternative care arrangements can be made to meet the client’s needs.