Medical assistance in dying and end‑of‑life decisions support for medical professionals
Learn what physicians and nurse practitioners’ roles and responsibilities are with respect to medical assistance in dying.
This information is intended for care providers. Learn more about medical assistance in dying and end-of-life decisions for patients.
Overview
Medical assistance in dying (MAID) became legal in Canada in June 2016, with the passage of Bill C‑14, which amended the Criminal Code and other federal acts with respect to medical assistance in dying.
Federal legislation sets out eligibility criteria for those who wish to request MAID, as well as the safeguards that a physician or nurse practitioner must follow to legally provide medical assistance in dying.
On March 17, 2021, the federal government passed Bill C‑7: An Act to Amend the Criminal Code (Medical Assistance in Dying). Among other changes, Bill C‑7:
- expanded eligibility criteria for medical assistance in dying to include persons whose natural death is not reasonably foreseeable
- established a separate set of safeguards for individuals whose natural death is not reasonably foreseeable
- made amendments to the safeguards for individuals whose natural death is reasonably foreseeable
- expanded data collection through the federal monitoring regime
Any request for medical assistance in dying may trigger reporting requirements for health care providers. Please see the Federal Regulations and Ontario's Hybrid Approach to the Reporting Requirements section below for more information.
Health care providers, including physicians, nurses, pharmacists and pharmacist technicians should refer to their regulatory colleges for additional professional guidance related to the provision of medical assistance in dying.
Patient eligibility
Federal legislation creates a framework for medical assistance in dying across Canada, including establishing eligibility criteria. The eligibility requirements are that the patient must:
- be eligible for publicly funded health care services in Canada (or in the applicable waiting period)
- be 18 years of age or older
- be capable of making health care decisions
- have a grievous and irremediable medical condition, which means:
- the patient has a serious and incurable illness, disease or disability
- the patient is in an advanced state of irreversible decline in capabilities
- the patient is enduring physical or psychological suffering, caused by the medical condition or the state of decline, that is intolerable to the person and cannot be relieved under conditions that they consider acceptable
- be making a voluntary request
- provide informed consent to medical assistance in dying
Bill C‑7 expanded eligibility to MAID to individuals whose death is not reasonably foreseeable and strengthened the safeguards for these applicants but included a temporary exclusion for persons whose sole underlying condition is a mental disorder.
Persons whose sole underlying condition is a mental disorder will be eligible for MAID as of March 17, 2024.
Informed consent to medical assistance in dying
For a patient whose natural death is reasonably foreseeable, the patient provides consent after having been informed of the means that are available to relieve their suffering, including palliative care.
For a patient whose natural death is not reasonably foreseeable, the patient provides consent:
- after having been informed of other means available to them, including counselling, mental health supports, disability supports, community services and palliative care
- after having been offered consultation with relevant professionals, as available and applicable
- after having discussed these means with the medical or nurse practitioner and given serious consideration to these means
Canadian patients should speak with their primary care provider or another clinician to determine steps needed to access medical assistance in dying in a province or territory that is not their primary residence.
Requests, assessments and access
A person should talk to a physician or nurse practitioner about options for care, which may include:
- medical assistance in dying
- palliative care
- other end-of-life care options
To make a formal request for medical assistance in dying, the person, if able, must make a verbal or written request.
A person’s request (verbal or written) may take any form including Clinician Aid A, a text message or an e-mail. It must be more than an inquiry or a request for information about MAID. The request does not have to be in the format required by the Criminal Code as a safeguard when MAID is provided (in other words duly signed, dated and witnessed).
To make a formal request in writing to receive medical assistance in dying, the federal legislation requires that the witnesses be at least 18 years of age and be able to understand the nature of the request for medical assistance in dying. The witness must 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
- be an owner or operator of any health care facility at which the person making the request is being treated or any facility in which that person resides
A paid personal support or health care worker can be an independent witness, provided they are not the medical assistance in dying provider or assessor of the person making the request.
Two independent physicians or nurse practitioners must confirm that a person meets the eligibility requirements. If natural death is not reasonably foreseeable, one of the two practitioners confirming eligibility must have or consult expertise in the condition that causes the person’s suffering. If neither the practitioner nor the other assessing practitioner has expertise in the condition that is causing the person’s suffering, one of the two assessing practitioners consulted with a medical practitioner who has expertise in the condition that is causing the person’s suffering and shared the results of the consultation with the other assessing practitioner.
Under the federal legislation, practitioners will be considered 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
- 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 person must understand that they can withdraw a request for MAID at any time in the process.
If a person is found not to meet the eligibility requirements by their physician or nurse practitioner, the person can seek a second medical opinion.
Substitute decision-makers
Family members or friends cannot act as substitute decision-makers for medical assistance in dying and have no legal authority to consent or override consent to or authorize medical assistance in dying on behalf of a person.
Assessment period when death is not reasonably foreseeable
If a person’s natural death is not reasonably foreseeable:
- a minimum period of 90 clear days is required for assessment of the request
- in some cases, if both evaluating practitioners agree that the person’s loss of capacity is imminent, the minimum 90-day assessment period could be shortened, but only if the eligibility assessments can be completed in a shorter amount of time and the assessors are both of the opinion that the person’s loss of capacity is imminent
Accessing medical assistance in dying: how to contact the care co-ordination service
Ontario has established a care co-ordination service to help the public and clinicians access information and supports for medical assistance in dying and other end-of-life options. Through the care co-ordination service, persons and their caregivers can receive information about:
- end-of-life options in Ontario, including hospice care
- other palliative care options in their communities
- medical assistance in dying
Persons and caregivers can also call the care co-ordination service to request to be connected to a physician or nurse practitioner who can provide medical assistance in dying services, such as eligibility assessments.
This service also supports access to medical assistance in dying by helping clinicians connect with a:
- physician or nurse practitioner who can provide the second assessment that is needed to evaluate and determine if a person meets all the eligibility criteria as set out in the Criminal Code of Canada
- community pharmacist or pharmacy technician who will dispense the drugs needed for medical assistance in dying
- physician or nurse practitioner who will prescribe or administer the drugs required for medical assistance in dying, if needed
Physicians, nurse practitioners, pharmacists, or pharmacy technicians who are unable or unwilling to provide medical assistance in dying services can also contact the care co-ordination service for assistance in making an effective referral. Please see the Conscientious Objection and Obligations to Patients section below for more information.
Health care providers, including physicians, nurses, pharmacists, and pharmacy technicians should refer to their regulatory colleges for additional professional guidance related to the provision of medical assistance in dying.
The care co-ordination service information line is available 24 hours a day, 7 days a week and may be reached at
Administering medical assistance in dying
The federal legislation allows:
- a physician or nurse practitioner to administer a substance directly to the person, such as through a drug injection
- a physician or nurse practitioner to prescribe or provide a substance to the person to self-administer, such as by orally ingesting drugs
An eligible person can request either option. For those who are covered by Ontario’s Health Insurance Plan (OHIP), the drugs and services required for medical assistance in dying are normally available at no cost to the person.
Physicians and nurse practitioners registered in Ontario can provide medical assistance in dying, either as the primary clinician or as the secondary/consulting clinician (who provides a written opinion confirming the person satisfies all the eligibility requirements for medical assistance in dying).
Pharmacists or pharmacy technicians will dispense the drugs used to provide medical assistance in dying.
Other health care professionals (such as, nurses, social workers) can support a physician or nurse practitioner providing medical assistance in dying. The federal legislation also allows them to provide information to a person on how medical assistance in dying is permitted in Canada. The federal legislation allows an individual, such as a family member, to help a person self-administer the drugs, provided that the person explicitly requests the individual's help.
The person must confirm consent immediately before medical assistance in dying drugs are administered by the clinician, or before a self-administered prescription is written and provided to the person. There are some instances where this requirement for final consent can be waived if certain criteria are met. Please see the Waiving final consent section below for more information.
In addition to complying with federal and provincial medical assistance in dying legislation in providing (or assisting in the provision of) medical assistance in dying, health professionals in Ontario must comply with any additional professional obligations required by their health regulatory colleges.
Physicians, nurse practitioners and those who assist them, as well as institutions that participate in the lawful provision of medical assistance in dying are protected from civil liability, except in cases of negligence, in accordance with Ontario's legislation.
Waiving final consent
The requirement for final consent immediately before medical assistance in dying is administered can be waived in certain circumstances. This may occur when a person’s natural death is reasonably foreseeable, and all the following criteria are met:
- the person was assessed as eligible for medical assistance in dying and satisfied all the relevant safeguards
- the person was informed that they are at risk of losing decision-making capacity before the scheduled date to receive medical assistance in dying
- the practitioner agrees to provide medical assistance in dying on the scheduled date if the person has lost capacity (or earlier, after loss of capacity, if agreed)
- the person gives consent in writing to the provider to receive medical assistance in dying on the scheduled date if they are no longer able to consent on that day
If, on the day of the medical assistance in dying procedure, the person has capacity to consent to medical assistance in dying, the practitioner must ensure that:
- the person gives express consent to receive medical assistance in dying
- consent given in advance is invalidated if the person demonstrates, by words, sounds or gestures, refusal or resistance to the administration of medical assistance in dying at the time of the procedure
Federal legislation also allows eligible persons who choose to pursue medical assistance in dying through self-administration to waive final consent.
This type of waiver of final consent would allow for a physician or nurse practitioner to follow through with providing medical assistance in dying to the person should self-administration produce complications.
Anyone who chooses to self-administer the substance for medical assistance in dying can make such an arrangement with their practitioner, regardless of their prognosis.
Dispensing drugs
Eligible persons will not have to cover the cost of drugs used to provide medical assistance in dying. In the hospital setting, drugs to administer medical assistance in dying would be dispensed by the inpatient pharmacy and covered by the hospital. For the administration of medical assistance in dying outside the hospital, such as a person self-administering the drugs in their home, drugs would be dispensed through community pharmacies at no charge to the person.
Under federal legislation, clinicians must inform the pharmacist or pharmacy technician that the prescription is intended for medical assistance in dying before a pharmacist or pharmacy technician dispenses the prescription. Clinicians should make arrangements with pharmacies as early as possible to avoid delays in processing a prescription for medical assistance in dying.
As with any unused medication, medical assistance in dying drugs should be disposed of according to existing protocols and programs that assist people in disposing of unused medications. Many pharmacies are part of the Return Program where they accept and safely dispose of unused medications.
Clinicians can obtain information on medical assistance in dying prescribing protocols from their respective regulatory college.
Clinicians or a person seeking assistance in connecting with a community pharmacist or pharmacy technician who will dispense the drugs needed for medical assistance in dying may call the care co-ordination service toll free at
Accommodations
The federal legislation requires that, if a person has difficulty communicating, physicians and nurse practitioners take all necessary measures to provide a reliable means by which the person can understand the information provided to them and communicate their decision with respect to medical assistance in dying.
Willing clinicians are permitted to use telemedicine to assess a person's request for medical assistance in dying, as long as care provided through telemedicine meets the requirements set out in federal legislation and all of the standards and expectations that apply to care provided in person.
Where medical assistance in dying can take place
A person can request access to medical assistance in dying from their clinicians whether they are in:
- hospital
- long-term care home
- hospice or palliative care facility
- in their own homes
Institutions that do not allow the provision of medical assistance in dying, or that have limits on how medical assistance in dying may be provided in the institution, are encouraged to make this information available to the public.
Regardless of any institutional policies with respect to medical assistance in dying, clinicians who work in institutions must meet the professional referral obligations established by their respective regulatory colleges.
Institutions are encouraged to develop policies with respect to medical assistance in dying in this context.
Conscientious objection and obligations
In Ontario, health regulatory colleges are responsible for regulating their respective professions in the public interest. In doing so, colleges may establish policies and standards that their members must comply with, including policies and standards regarding medical assistance in dying.
The College of Physicians and Surgeons of Ontario’s Professional Obligations and Human Rights policy requires that when physicians are unwilling to provide certain elements of care for reasons of conscience or religion, an effective referral to another healthcare provider must be provided to the person.
An effective referral means “a referral made in good faith, to a non-objecting, available, and accessible physician, other health care professional, or agency.” Referrals must be made in a timely manner.
Similar obligations of nurses, nurse practitioners, pharmacists and pharmacy technicians have been established by their respective regulatory colleges as part of existing codes of ethics.
Clinicians who are unwilling to provide medical assistance in dying can either make a referral using their own professional networks or institutional policies, or they may call the care co-ordination service at
If a person has questions about their clinician's professional obligations, the person can contact the applicable regulatory college.
Clinicians must meet the professional obligations established by their respective regulatory colleges. Institutions are encouraged to develop policies with respect to medical assistance in dying in this context.
Institutions are encouraged to inform residents and others of any institutional position on medical assistance in dying, including any and all limits on allowing its provision, so persons can make informed choices about their care options.
Monitoring and reporting medical assistance in dying
Monitoring deaths from medical assistance in dying
Ontario provides voluntary, standardized clinician aids that reflect the requirements set out in federal legislation. Physicians and nurse practitioners are strongly encouraged to complete the clinician aids in addition to their usual medical record-keeping requirements, as outlined by their regulatory colleges, and keep them on file. These clinician aids are voluntary and can be found on the Government of Ontario’s Central Forms Repository.
Reporting deaths from medical assistance in dying
Under Ontario law, physicians and nurse practitioners who provide medical assistance in dying are required to notify the Office of the Chief Coroner of the death and provide the Office of the Chief Coroner with the facts and circumstances of the death.
Once a death is reported, the coroner/MAID death review team will determine whether it is appropriate to investigate the death. Each case is different, and the Office of the Chief Coroner cannot determine in advance of any death whether an investigation is warranted. The Office of the Chief Coroner cannot provide guidance or recommendations to a practitioner in advance of a death.
If the Office of the Chief Coroner is of the opinion that the death ought to be investigated, and investigates the death, the Office of the Chief Coroner is required to complete and sign the medical certificate of death.
However, if the Office of the Chief Coroner is of the opinion that the death does not require an investigation, then, in accordance with applicable law, the physician or nurse practitioner is required to complete and sign the medical certificate of death.
Clinicians will need to work with the Office of the Chief Coroner to provide the information the office needs to make the process as efficient, effective and appropriate as possible. Clinicians should refer to the Office of the Chief Coroner's Process Overview and Checklist to better understand the process when reporting a medical assistance in dying death and the pieces of information and documentation frequently requested by the Office of the Chief Coroner.
Persons who have chosen to self-administer medical assistance in dying are encouraged to share their plans and the contact information of their attending clinician with a family member/s or friend/s to help ensure authorities are aware that their death was planned. In the event of an investigation, the coroner will only obtain information necessary to fulfill their duties.
For questions about the Office of the Chief Coroner’s investigations process, contact occ.inquiries@ontario.ca or
Federal regulations and Ontario's hybrid approach to the reporting requirements
Federal legislation sets out reporting requirements for medical assistance in dying. All practitioners who assess medical assistance in dying eligibility (prior to receiving a formal request), and any person who undertakes a preliminary assessment of an individual’s eligibility will be required to report information in accordance with the federal Regulations for the Monitoring of Medical Assistance in Dying. Pharmacists and pharmacy technicians are also required to meet federal reporting requirements if they dispense a substance for medical assistance in dying.
According to federal reporting requirements (in other words, federal Minister of Health regulations) for medical assistance in dying any written or verbal request for medical assistance in dying received on or after November 1, 2018, may trigger reporting requirements. The following health care providers are subject to the reporting requirements in the federal regulation:
- physicians or nurse practitioners who receive a person's request for medical assistance in dying and encounter one of the following seven scenarios:
- medical assistance in dying was provided by administering a substance to a person
- medical assistance in dying was provided by prescribing or providing a substance for self-administration by the person
- a person was referred to another practitioner or a care coordination service, or a transfer of care occurred as a result of the request
- a person was found to be ineligible for medical assistance in dying
- the person was found to be eligible for medical assistance in dying, but the practitioner subsequently determined that a safeguard had not been met and therefore MAID was not provided
- the clinician becomes aware that the person has withdrawn their request for medical assistance in dying
- the clinician becomes aware that the person has died from a cause other than medical assistance in dying
- pharmacists or pharmacy technicians who dispense a substance in connection with the provision of medical assistance in dying
To minimize the reporting burden on clinicians, Ontario has developed a hybrid approach to work with the federal reporting regulations.
In cases where a medically assisted death has occurred (clinician and self-administered cases), physicians and nurse practitioners are required to report to the Office of the Chief Coroner after confirming or becoming aware that the person has died
- the Office of the Chief Coroner will collect information from physicians and nurse practitioners on all medically assisted deaths, and will report to the federal Minister of Health (in other words, Heath Canada) on their behalf
In all cases where a request was made, but a medically assisted death has not occurred, physicians and nurse practitioners are required to report to Health Canada via the Canadian MAID Data Collection Portal.
This includes cases where a written request was received, but a medically assisted death did not occur (in such cases as the clinician who received the written request found the person to be ineligible, the person was referred, the person withdrew the request for medical assistance in dying, or the person died from a cause other than medical assistance in dying). Under these scenarios, the practitioner has up to 30 calendar days to file a report. The 30 days starts after one of those four events, not as soon as the written request is submitted to the practitioner. If none of the aforementioned events happens within 90 calendar days of the practitioner receiving the request, the practitioner is not required to report to Health Canada.
This also includes cases where a physician or nurse practitioner has provided a prescription for self-administered medical assistance in dying, but a medically assisted death has not occurred (in such cases as the person died from a cause other than the administration of medical assistance in dying, the person is still alive, or the outcome is unknown). Under these scenarios, the practitioner must report no earlier than 90 days and no later than 120 days after the prescription or substance is provided. However, if the practitioner becomes aware of the person's death from a cause other than the administration of medical assistance in dying in less than 90 days, the practitioner may report to Health Canada before the 90th day. If the practitioner becomes aware of the person's death from medical assistance in dying in less than 90 days, the practitioner must report to the Office of the Chief Coroner immediately after confirming or becoming aware that the person has died.
In instances where a non-practitioner conducts a preliminary assessment of a person’s request for medical assistance in dying and finds them ineligible, this non-practitioner (referred to as a preliminary assessor) will still be required, under federal reporting regulations, to report the request and their determination of ineligibility to the Canadian MAID Data Collection Portal within 30 days after the day on which the determination of ineligibility is made.
All pharmacists or pharmacy technicians who have dispensed a substance in connection with the provision of medical assistance in dying are required to report to Health Canada via the Canadian Medical Assistance in Dying Data Collection Portal within 30 days after the day of dispensing
Table 1: The following table provides scenarios where a written request is received and medical assistance in dying has been provided.
| Scenario | Whom to report to | Deadline to report |
|---|---|---|
Clinician-Administered medical assistance in dying You provided medical assistance in dying by administering a substance to a person | Office of the Chief Coroner | Within one business day after the person has died |
Person-Administered medical assistance in dying You provided medical assistance in dying by prescribing or providing a substance for self-administration by the person | Office of the Chief Coroner | Within one business day after becoming aware the person has died |
Table 2: The following table provides scenarios where a written request is received and a medically assisted death has not occurred.
| Scenario | Whom to report to | Deadline to report | Related rules |
|---|---|---|---|
Person referred You referred a person to another practitioner or a care coordination service or transferred their care as a result of the request | Health Canada | Within 30 days after the day of referral/ transfer | You do not need to report if you refer or transfer a person more than 90 days after the day you receive the written request. If you report with respect to a referral or transfer of care, you are not required to report again for the same written request unless you later provide medical assistance in dying. |
Person ineligible You found a person to be ineligible for medical assistance in dying | Health Canada | Within 30 days after the day ineligibility is determined | You do not need to report if you find a person ineligible more than 90 days after the day you receive the written request. If you report on a finding of ineligibility, you are not required to report again for the same written request unless you later provide medical assistance in dying. |
Person eligible but safeguard not met You found a person to be eligible for MAID, but subsequently determined that a safeguard had not been met and therefore MAID was not provided | Health Canada | Within 30 days after the day on which the subsequent determination is made | Not applicable |
Request withdrawn You became aware that the person withdrew the request for medical assistance in dying | Health Canada | Within 30 days after the day you became aware of the withdrawal | You do not need to report if you become aware, more than 90 days after the day you receive the written request, that a person has withdrawn their request. If you report on the withdrawal of a request, you are not required to report again for the same written request unless you later provide medical assistance in dying. If the person has not contacted you after the initial written request, you are not required to actively seek out information about whether the person has withdrawn the request, whether or not you have assessed them. In such a situation, you do not need to report. |
Death — other cause You became aware of the death of the person from a cause other than medical assistance in dying | Health Canada | Within 30 days after the day you became aware of the person's death | You do not need to report if you become aware, more than 90 days after the day you receive the written request, that a person has died of a cause other than medical assistance in dying. If the person has not contacted you after the initial written request, you are not required to actively seek out information about whether the person has died of a cause other than medical assistance in dying, whether or not you have assessed them. In such a situation, you do not need to report. |
| Self-Administered Medical Assistance in Dying Prescription Provided — No Medically Assisted Death (person alive, died from another cause, or outcome is unknown) | Health Canada | No earlier than 90 days and no later than 120 days after the substance was prescribed. If the practitioner becomes aware of the person's death from any cause in less than 90 days, the practitioner may report to Health Canada before the 90th day | Not applicable |
Table 3: The following table provides a scenario where a non-practitioner (preliminary assessor) performs a preliminary assessment for a person for the purposes of medical assistance in dying.
| Scenario | Whom to report to | Deadline to report | Related rules |
|---|---|---|---|
| Determination of ineligibility | Health Canada | Report within 30 days after the day on which the determination of ineligibility is made | The 30 days start after the determination of ineligibility, not the day after the preliminary assessor receives the request. Preliminary assessors are only required to report a determination of ineligibility and have no other reporting obligations under federal regulations. |
Under Ontario's hybrid approach, there will be duplicative reporting for only a small fraction of self-administered medical assistance in dying cases that result in a medically assisted death. Duplicative reporting would only occur if a medically assisted death occurred after the 90th day from when the substance for self-administration was prescribed and the physician or nurse practitioner had already reported to Health Canada.
In this scenario, a physician or nurse practitioner would be required to report to Health Canada between the 90–120 day period stipulated in federal regulations, and then to the Office of the Chief Coroner immediately after becoming aware of the self-administered medically assisted death.
The requirement to provide information for monitoring purposes is triggered by the assessment of medical assistance in dying eligibility or receipt of a verbal or written request for medical assistance in dying.
According to Health Canada, a person's request (verbal or written) may take any form including a text message, an e-mail, or Ontario’s Clinician Aid A.
It must, however, be more than an inquiry or a request for information about medical assistance in dying.
The request does not have to be in the format required by the Criminal Code as a safeguard when medical assistance in dying is provided (in other words, duly signed, dated and witnessed) to require reporting.
In cases of a medically assisted death, only the clinician who provides medical assistance in dying must report to the Office of the Chief Coroner. If the first assessor is not the clinician providing medical assistance in dying, they may need to report a referral to Health Canada.
The above summary was provided for informational purposes only. For more detailed information about the federal reporting requirements for medical assistance in dying, please refer to the federal regulations and/or Health Canada's website. For questions about Ontario's hybrid reporting approach, contact endoflifedecisions@ontario.ca.
Funding for medical assistance in dying services
Physician and nurse practitioner activities for medical assistance in dying are funded through existing OHIP billing codes for physician services, and salaried contracts for nurse practitioners.
Existing compensation mechanisms are also employed to compensate pharmacists and other health care professionals involved in the provision of medical assistance in dying.
The cost of drugs for all eligible persons is also covered for both clinician-administered and self-administered medical assistance in dying provisions, in any location.
Virtual care
Under the new OHIP insured virtual care framework, the Ministry of Health and Ontario Medical Association have agreed to implement a new pricing structure for virtual care that more appropriately reflects the characteristics of services that can be provided through different modalities (such as video vs. telephone) and within different types of patient-physician relationships. This new framework took effect on December 1, 2022.
All medically necessary virtual care services, including services related to the provision of medical assistance in dying, will continue to be insured under OHIP. Patients will continue to have access to clinically appropriate virtual care, where virtual care is the appropriate modality of service.
If you have any questions regarding the new OHIP insured virtual care model, please contact the Provider Services Branch at providerservicesbranch@ontario.ca.