A look at assisted-dying guidelines across Canada

The Colleges of Physicians and Surgeons in every province and one territory have issued guidelines that doctors must follow in providing medical assistance in dying.

British Columbia

• Two independent physicians must agree a patient meets the criteria set out by the Supreme Court.
• The patient must be eligible for publicly funded health care, and able to give free and informed consent throughout the process.
• No advance requests.
• The patient must consistently express a desire for an assisted death over a “reasonable period of time,” 15 days in most cases, but dependent on each patient’s condition and circumstances.
• Formal written request required, signed by the patient and one witness who is not related, entitled to a portion of the patient’s estate, or involved in treatment.
• Physicians may refuse to provide assisted death but they must provide “an effective transfer of care.”
• The government has directed each provincial health authority to appoint a co-ordinator for medical assistance in dying.

Alberta

• Two doctors must independently agree the patient meets all criteria set out by the Supreme Court.
• Patient must be “competent throughout the process.”
• No advance requests.
• The college notes that legal precedent recognizes mature minors as adults in their ability to consent, but recommends “a careful and conservative approach.”
• Doctors may refuse to provide an assisted death but have “an obligation” to provide patients with timely referrals to doctors who will perform the service.
• Requests must be in writing, signed by the patient and two witnesses, at least one of whom can not be related to the patient, entitled to any portion of the patient’s estate or involved in treatment of the patient.
• Where capacity is unclear, or where a person is suffering from depression or other mental illness, a psychiatric or psychological consultation is required.
• A period of reflection of 14 days from initial request to final consent is recommended.

Saskatchewan

• Two doctors must agree the patient meets the Supreme Court criteria. Adult is defined as at least 18.
• Patient must repeatedly give free, informed consent throughout the process.
• No advance requests.
• Attending doctor must ensure the patient has consistently expressed a desire for an assisted death “over a reasonable period of time,” the length of which is dependent on the patient’s condition.
• Physicians may refuse to provide an assisted death but must arrange “timely access” to another doctor or resource.
• Patient must fill out a prescribed form confirming informed consent.

Manitoba

• At least two physicians must independently agree the patient meets the Supreme Court’s criteria. Adult is defined as age 18.
• Independent psychiatric assessment required where a patient does not have a terminal illness (prognosis of less than six months) or is not suffering from a “catastrophic and irreversible physical injury” or intractable physical pain or an advanced state of irreversible, significantly impaired function or imminent decline to that state. The assessment must rule out a treatable psychiatric disorder that is impairing patient’s ability to tolerate suffering or assess treatment options.
• Each doctor must meet at least once with the patient to ensure the patient is competent, fully informed and has made “a clear and settled” choice, without undue coercion or influence.
• No advance requests.
• A waiting period of at least seven days, except for those whose death is imminent.
• Written consent, signed by the patient.
• Physicians may refuse to provide an assisted death or to refer a patient to another doctor but must provide “timely access to a resource” that will provide the information.

Ontario

• Two doctors must agree the patient meets the Supreme Court’s criteria. College recommends only patients in Canada, covered by publicly funded health care, be eligible. It notes the court did not define the term “adult.”
• No advance requests.
• Physicians may refuse to provide an assisted death, but must make an “effective referral” to an available, accessible physician or agency that will.
• The Premier says the province will set up a referral service so physicians unwilling or unable to provide assisted dying can connect patients with those who are willing.
• An unspecified waiting period is required, length depending on the patient’s condition.
• A formal written request is required, signed by the patient, the attending physician and an independent witness.
• The Health Minister says drugs for medically assisted dying will be available at no cost.

Quebec

Quebec is the only province that has enacted a law governing assisted dying. The law, drafted before the Supreme Court ruling, requires that:

• A patient must be covered by provincial health care, be of “full age” and capable of giving consent, be at the end of life, suffering from a serious and incurable illness, in an advanced state of irreversible decline and experiencing constant and unbearable physical or psychological suffering which can’t be relieved in a manner acceptable to the patient.
• Two doctors must agree patient meets the criteria for a medically assisted death.
• Request must be made in writing.
• No advance requests.
• Physicians may refuse to provide an assisted death but must immediately notify authorities who will take steps to find another doctor.

New Brunswick

• Patient must meet criteria set out by the Supreme Court, which is further defined as suffering from a grievous illness for which there is no cure and which will eventually cause death. The college notes an assisted death could be available to any patient who can legally consent. In New Brunswick, the age of legal consent is 16.
• Patients with progressive illnesses who are also suffering from “intractable depression” are not automatically ineligible but doctors should proceed with “extraordinary caution” in such cases.
• Physicians may refuse to provide medical help in dying or to make a direct referral but must provide patients with information on accessing an assisted death.
• Doctor must be satisfied that patient’s wish is “persistent, consistent and unshakable,” documenting patient’s request for an assisted death at least twice, two weeks apart, and again just before administering an assisted death.
• No advance requests.
• Administering physician should obtain additional medical opinions as deemed appropriate to confirm prognosis, alternative options, and patient’s capacity to make a free, fully informed choice.

Nova Scotia

• Two doctors must agree a patient meets criteria set out by the Supreme Court. Adult is defined as at least 19.
• No advance requests.
• Physicians may refuse to provide an assisted death for reasons of conscience, but college recommends they provide “an effective referral” to another doctor.

Prince Edward Island

• Two doctors must agree the patient meets the criteria set out by the Supreme Court. Must have a current provincial health care card and the capacity to freely and repeatedly consent throughout the process. Adult is defined as at least 18.
• Request must be in writing, witnessed by two independent persons with no connection to the patient.
• No advance requests.
• Physicians may refuse to provide an assisted death but must provide, or arrange to be provided, the patient’s chart to other physicians.
• Doctor must ensure patient has repeatedly expressed a desire for an assisted death “over a reasonable period of time,” which may vary depending on patient’s condition.

Newfoundland and Labrador

• Two doctors must agree a patient meets the criteria set out by the Supreme Court. Adult is defined as at least 19.
• No advance requests.
• Written request required, signed by patient and one independent witness.
• Physicians may refuse to provide an assisted death, but should provide “timely access” to another doctor or information resource.

Yukon

• Two doctors must agree the patient meets the Supreme Court criteria. The Yukon Medical Council notes it is uncertain whether a medically assisted death could be legally available to minors.
• Patient must maintain decision-making capacity throughout the process, up to time of dying.
• No advance requests.
• Written request for assisted death required, signed by patient and two witnesses, one of whom is not related, entitled to any benefit from the patient’s estate or involved in the provision of treatment.
• If a physician believes the patient suffers from psychiatric or psychological disorder or depression that could impair capacity to make an informed choice, the patient must be referred for assessment.
• A waiting period of 14 days is recommended.
• Physicians may refuse to provide assisted death but must arrange “timely access” to another doctor or resource.