Guidance related to the new Medical Assistance in Dying legislation for Alberta’s nurses has now been released by the Tri-Nursing Group (CRPNA, CARNA, CLPNA).
On June 17, 2016, an Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying)
(also referred to The Act in this document) received Royal Assent introducing legislation that allows a person to request and receive medical assistance in dying in Canada under limited circumstances. This legislation revises the Canadian Criminal Code to include exemptions for health-care providers who may help to provide medical assistance in dying under the direction of a physician or nurse practitioner.
revises the Canadian Criminal Code to include exemptions from otherwise applicable criminal offenses for health-care providers who help to provide medical assistance in dying in defined circumstances. Only physicians or nurse practitioners may directly provide a person with medical assistance in dying.
On June 17, 2016, This Act passed Royal Assent and became law.
The Alberta Health ministerial directive D3-2016
outlines that Alberta Health Services shall coordinate and facilitate access to health services relating to medical assistance in dying. Anyone that is seeking additional information related to medical assistance in dying may be referred to their physician or nurse practitioner, can contact Health Link at 811 or contact the Alberta Medical Assistance in Dying Care Coordination Team via email at MAID.CareTeam@ahs.ca.
You have asked us the following questions:
Frequently Asked Questions for Alberta’s Nurses Who is eligible for medical assistance in dying?
Only physicians or nurse practitioners can assess a client’s eligibility for and provide medical assistance in dying. The Act to amend the Criminal Code
outlines the criteria required for the eligibility of medical assistance in dying. It states:
What is Medical Assistance in Dying?
The Act defines medical assistance in dying as:
(a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or
(b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.
Eligibility for medical assistance in dying
241.2 (1) A person may receive medical assistance in dying only if they meet all of the following criteria:
(a) they are eligible?—?or, but for any applicable minimum period of residence or waiting period, would be eligible?—?for health services funded by a government in Canada;
(b) they are at least 18 years of age and capable of making decisions with respect to their health;
(c) they have a grievous and irremediable medical condition;
(d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and
(e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care.
Grievous and irremediable medical condition
(2) A person has a grievous and irremediable medical condition only if they meet all of the following criteria:
(a) they have a serious and incurable illness, disease or disability;
(b) they are in an advanced state of irreversible decline in capability;
(c) 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; and
(d) their natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.
What does this mean for RPNs in Alberta?
The passing of The Act
allows nurses to participate in medical assistance in dying when under the direction of a physician or nurse practitioner. It is essential for nurses to understand that the RPN, RN and LPN will have a limited role in medical assistance in dying. Only a physician or nurse practitioner may administer the substance that causes the death. We recommend that any nurse who has been asked to participate in medical assistance in dying contact their regulatory college (CRPNA, CARNA or CLPNA) for advice.
What does this mean for Nurse Practitioners (NPs) in Alberta?
CARNA has been collaborating with Alberta Health, Alberta Health Services, the College of Physicians and Surgeons of Alberta, and the Alberta College of Pharmacists to develop a regulatory framework for medical assistance in dying (MAID) that is aligned, legally sound, safe and consistent with the amended Criminal Code. This framework includes additional provincial safeguards for consistency and patient safety.
Through an Order in Council, Alberta Health in conjunction with CARNA, has developed the NP Medical Assistance in Dying Standards of Practice
that NPs providing MAID must meet. If you have any questions, please contact CARNA at firstname.lastname@example.org.
What are the requirements for nurses assisting with medical assistance in dying?
End of life care with the goal of a peaceful death has always been a role of nursing. Nurses engage in conversations about end of life and help facilitate and navigate information to assist clients in making informed decisions. This role has not changed. The passing of The Act
allows nurses to participate in medical assistance in dying when under the direction of a physician or nurse practitioner. Nurses that assist in medical assistance in dying when under the direction of a physician or NP must ensure the following requirements are met:
1. No member of the health-care team except for a physician or nurse practitioner may administer the substance that causes the death.
2. No member of the health-care team except for a physician or nurse practitioner can ensure that the eligibility parameters outlined in The Act
and the Amended Standards are met.
o RPNs/RNs/LPNs are not expected to have assessed the client personally for medical assistance in dying and therefore are not in a position to determine that the client meets the eligibility parameters. Nurses should however ensure that they are aware of these eligibility parameters and have a reasonable basis to believe that the physician or NP providing MAID has assessed the clients eligibility, including complying with legislation and all safeguards set out in the legislation. If the RPN/RN/LPN has any questions about the eligibility criteria or safeguards, they should inquire directly with the physician or NP.
3. Nurses should ensure that they are aware of and follow all federal and provincial legislation (including the new wording of The Act), provincial directives, regulatory body standards/guidance and employer protocols, policies and procedures on medical assistance in dying.
4. Nurses can support the access to accurate and objective information about medical assistance in dying to clients so that they may make informed decisions about their care.
5. Nurses must ensure that they have the competency to do the required assisted tasks (for example: starting an IV).
6. Nurses must document their nursing care appropriately in accordance with the standards of practice of their profession.
Considerations for nursing practice
Despite any of the authorization to provide nursing care, nurses must always restrict themselves to activities which they are competent to perform and that are appropriate to their area of practice and the procedures being performed. Below are some considerations for nursing practice in regards to medical assistance in dying.
Route of administration
* What medications are involved in the protocol? What are the routes of administration?
* If intravenous, what is the volume of medication/s? Is a secondary IV required? What is the appropriate gauge of the IV catheter?
* If oral, is there any requirement to establish an IV as a secondary route of administration?
* Is the family or others going to be present during the medical assistance in dying process? What support will be needed?
* When a client self-administers the substance, will the client be able to take the oral medication independently? With the client’s explicit request, the law allows for a person to aid the client to self-administer a medication to cause death, provided that medication has been prescribed by a physician or NP for the client for medical assistance in dying.
* Consider the resources available for the different environments; homecare, inpatient unit.
* Consider the positioning of the client for medication administration.
* Does the environment allow for this positioning?
* What supporting information is needed for the client, family and care team?
* Does the family have adequate social, psychological and spiritual supports in place?
* Are they informed about the process, what they may see and experience before, during and after?
* Have arrangements for the client been made following the death of the client? (i.e. funeral)
* Is a debriefing process in place for the care team providing medical assistance in dying?
* Is a debriefing process in place for discussing the process and outcomes from the perspective of the family?
* Be aware of legislative requirements specific to medical assistance in dying documentation. Document according to organizational and procedural guidelines
* Assess your own competencies for end of life care:
o Assessment and management of pain, physical symptoms, and psychosocial and spiritual needs
o Ability to be present and attend to the end of life needs of the client and family
o Awareness of own responses to suffering and death and seek support as needed
* Seek out relevant education for competency and lifelong learning in end of life care
What do I say if a client wants more information on or is seeking medical assistance in dying?
Acknowledge the request for information in a competent and compassionate way. Know that your client’s request for additional information or further consultation on medical assistance in dying is their constitutional right and as nurses we can support their access to accurate and objective information so that they may make an informed decision about their care. Be aware that a request for information on assisted death may also be a way for the client to engage in a meaningful conversation about health issues or end of life care and support.
Whether or not a nurse chooses to participate in medical assistance in dying, he/she has an obligation to:
* Openly discuss the client’s concerns, unmet needs, feelings, and desires about their care.
* Refer the client to the Alberta medical assistance in dying care coordination team if unable to support their access to information.
“For greater certainty, no social worker, psychologist, psychiatrist, therapist, medical practitioner, nurse practitioner or other health care professional commits an offence if they provide information to a person on the lawful provision of medical assistance in dying.”
The Alberta Health ministerial directive D3-2016
outlines that Alberta Health Services shall coordinate and facilitate access to health services relating to medical assistance in dying. Anyone that is seeking additional information related to medical assistance in dying may be referred to their physician, nurse practitioner or can contact Health Link at 811 or contact the Alberta Medical Assistance in Dying Care Coordination Team via email at MAID.CareTeam@ahs.ca.
Nurses should only provide information on medical assistance in dying on the client’s explicit request.
Nurses should not initiate a discussion on medical assistance in dying with clients because this could be interpreted as counseling a person to die or the client may feel pressured.
Nurses who provide information about medical assistance in dying should ensure that the information is correct before it is provided and should not guess or speculate
. Where unsure, the nurse should consult with reliable sources of information and may wish to consider an early referral to authoritative sources of information such as the Alberta Medical Assistance in Dying Care Coordination Team. Nurses should also endeavor to remain as neutral as possible and refrain from advocating for or against medical assistance in dying.
In addition, the nurse must be aware that there are new criminal offences with serious penalties for tampering with documents related to medical assistance in dying.
Highlight to your client that nurses:
* work to relieve pain and suffering through appropriate and effective symptom and pain management, including fostering comfort and advocating for adequate relief of discomfort
* introduce palliative care as an option to consider, if not already done, to support symptom management
* ensure that clients in their care receive all of the information they need to make informed decisions related to their health and wellbeing including medical assistance in dying
* advise the client that you will inform their physician or nurse practitioner in a timely manner, about their request to have a conversation and receive more information about medical assistance in dying
* follow the organizational policies that detail who to alternately contact for this specific query if the physician or nurse practitioner is not available
* ensure the client understands all additional supports available to them and is not seeking medical assistance in dying due to lack of supports
* document the care provided and any request for information on medical assistance in dying in the client record according to professional standards
Engage the client in meaningful communication to clearly understand their health needs. Continue your nursing assessments and provide care as you always would with empathy, respect and compassion. Reinforce your commitment to support and help them with their care needs and any decisions they make. Your nursing role is to continue providing safe, competent, compassionate, ethical nursing care.
What if medical assistance in dying is against my beliefs or values?
Nurses are not required to participate in medical assistance in dying if it is in conflict with their moral beliefs and values (conscientious objection). Legislation does not force any person to provide or help in the provision of medical assistance in dying.
If you are asked to participate in any aspect of lawful medical assistance in dying and you choose not to participate due to reasons of conscience, ensure you immediately:
* Notify your employer so that alternative care arrangements can be made and/or
* Refer the client to the Alberta Medical Assistance in Dying Care Coordination Team via email at MAID.CareTeam@ahs.ca.
Reassure the client that they will not be abandoned. No personal moral judgments about the beliefs, lifestyle, identity or characteristics of the client should be expressed by the nurse. Until a replacement caregiver is found, a nurse must continue to provide nursing care, as per a client’s care plan, that is not related to activities associated with medical assistance in dying.
The issue of ending life raises many ethical considerations and generates differences of opinion. Because clients may make choices that challenge or conflict with the moral values of health professionals who care for them, it becomes necessary to recognize the rights of all persons with conflicting views with the care team. Nurses need to respect their own moral beliefs while at the same time respecting the moral beliefs of others.
If you have any questions about conscientious objection, please contact your professional regulatory college (CRPNA, CARNA or CLPNA) for information.
Can a nurse sign the medical assistance in dying request form as an independent witness?
outlines that a request for medical assistance in dying must be signed by two independent witnesses. Health care providers who provide care to the recipient of medical assistance in dying are not permitted to act as independent witnesses under section 241.2(5) of The Act.
As nurses are members of the healthcare team providing care to clients, they should not sign as an independent witness.
The Act states:
(5) Any person who is at least 18 years of age and who understands the nature of the request for medical assistance in dying may act as an independent witness, except if they
(a) 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;
(b) are 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;
(c) are directly involved in providing health care services to the person making the request; or
(d) directly provide personal care to the person making the request.”
How do I prepare for questions on medical assistance in dying?
Familiarize yourself with federal and provincial regulations, professional regulatory college standards and guidelines and organizational policies on medical assistance in dying. Participate in and provide feedback to provincial, organization, professional and local work area surveys. Participate in conversations on this topic with your team to promote understanding. Call your professional regulatory college with any questions.
What is CRPNA doing?
CRPNA has been part of a nursing working group consisting of the three nursing regulators in Alberta to establish collaborative guidance for nursing members. We are currently developing collaborative guidelines for MAID.
CRPNA is also working with Alberta Health and Alberta Health Services to recognize the role of all nurses in medical assistance in dying and collaborate to achieve the necessary legal protection, guidance and education.
Who can I call if I have further questions?
If you are an RPN that has been asked to participate in Physician Assisted Death and are considering participating, please contact the CRPNA for consultation.
College of Registered Psychiatric Nurses of Alberta
Practice Consultant, 1-877-234-7666 or 1-780-434-7666
Where can I learn more?
An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying)
Carter v. Canada (Attorney General), 2015 SCC 5
Alberta Health Services
Alberta Health Services (2016). Medical Assistance in Dying
Alberta Health Services (2016). Medical Assistance in Dying Policy. AHS
Employment and Family Assistance Program (EFAP) Resources
Covenant Health (2016). Response to Medical assistance in Dying.
Covenant Health EFAP Resources
Canadian Nurse Protective Society (CNPS)
- Although this is an NP/RN resources, some of the content may be beneficial for all nurses in learning more about medical assistance in dying
College of Physicians and Surgeons of Alberta (2016). Standards and Advice to the Profession.
Options for End of Life Care
Please refer to your regulatory Code of Ethics for additional information: