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Medical Asistance in Dying: Standards


​Standards

Untitled Document

1.

Nurse practitioners participating in any aspect of medical assistance in dying understand and comply with the Criminal Code and other legislation, the BCCNP standards of practice, and provincial and organizational policies and procedures related to medical assistance in dying.

2.

Nurse practitioners will have a complete and full discussion with the client about medical assistance in dying that provides the client with the information required to make informed decisions about medical assistance in dying, including information about the means that are available to relieve the client’s suffering, including palliative care.

3.

Nurse practitioners ensure that all necessary measures are taken to provide a reliable means by which the client will understand the information that is provided to them and communicate their decision, including when the client has difficulty communicating.

4.

Nurse practitioners must inform the client requesting medical assistance in dying of the following and the information must be included in the client’s medical record with a copy provided to the client:

 

a.

the client’s diagnosis and prognosis

 

b.

feasible alternatives (including comfort care, palliative care and pain control)

 

c.

option to withdraw the request for medical assistance in dying at any time

 

d.

risks of taking the prescribed substances intended to cause death

5.

Nurse practitioners assess the cultural and spiritual needs and wishes of the client seeking medical assistance in dying and explore ways the client’s needs could be met within the context of the care delivery.

6.

Nurse practitioners work with their organizations and other members of the health care team to ensure that the client requesting medical assistance receives high quality, coordinated and uninterrupted continuity of care and, if needed, safe transfer of the client’s care to another health care provider.

7.

Nurse practitioners acting as an assessor or assessor-prescriber must ensure clients requesting medical assistance in dying meet the following eligibility criteria, as set out in the Criminal Code, including that the client:

 

a.

is eligible for publicly funded health-care services in Canada

 

b.

is at least 18 years of age and capable of making decisions with respect to their health

 

c.

has a grievous and irremediable medical condition, which means meeting all of the following criteria:

 

 

i.

they have a serious and incurable illness, disease or disability

 

 

ii.

they are in an advanced state of irreversible decline in capability

 

 

iii.

the illness, disease, disability or state of decline causes them enduring physical or psychological suffering that is intolerable to them and cannot be relieved under conditions that they consider acceptable

 

 

iv.

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 they have remaining

 

d.

has made a voluntary request in writing for medical assistance in dying that, in particular, was not made as a result of external pressure

 

e.

has given 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

8.

Nurse practitioners acting as an assessor or assessor-prescriber must ensure that:

 

a.

the client requesting MAiD is competent and able to give free and informed consent to MAiD. Consent cannot be given for MAiD through an alternate or substitute decision-maker, or a personal advance directive.

 

b.

both assessors are satisfied that the client is mentally capable of making a free and informed decision with respect to medical assistance in dying at the time of the request and throughout the process.

 

c.

if either assessor is unsure that the client has capacity to consent to medical assistance in dying the client must be referred to another practitioner, with expertise in capacity assessment (e.g., a psychologist, psychiatrist, neurologist, geriatrician, or family physician/general practitioner with additional training and expertise) for a further capacity assessment.

9.

Nurse practitioners acting as an assessor-prescriber must ensure that the client maintains mental capacity for medical assistance in dying in order to proceed. If at any time during the progression of the client’s condition, the client loses the mental capacity to rescind their decision, MAiD ceases to be an option.

10.

One of the assessors, but not both, may provide their assessment by telemedicine. Nurse practitioners must ensure that during the telemedicine assessment, another regulated health professional is in physical attendance with the client to act as a witness to the assessment.

Notice: March 27, 2020 (updated April 22, 2020, for clarity.) Effective immediately and for the duration of the COVID-19 public health emergency in British Columbia, the standard allowing only one assessor to conduct a telemedicine assessment for a client requesting MAiD is temporarily rescinded. Both assessors may conduct the assessment by telemedicine. Telemedicine assessments must meet the requirements set out in federal legislation as well as the standards and expectations that apply to in-person assessments. For MAiD assessments, telemedicine includes video of sufficient quality to ensure expected safeguards are in place. A telephone interview is not sufficient in most circumstances.

Notice: March 27, 2020. Effective immediately and for the duration of the COVID-19 public health emergency in British Columbia, the requirement for a regulated health professional to be in physical attendance with the client to act as a witness to a telemedicine assessment is temporarily subject to the following exception: No witness is required for a telemedicine assessment if a regulated health professional is not reasonably available for that purpose.

11.

Nurse practitioners acting as an assessor-prescriber must, before prescribing, providing or administering medical assistance in dying to a client as permitted under the Criminal Code:

 

a.

be of the opinion that the client meets all of the eligibility criteria established for medical assistance in dying

 

b.

ensure that the request for medical assistance in dying was a voluntary request and was not made as a result of external pressure

 

c.

ensure that the request was signed and dated after the client was advised by a physician or nurse practitioner that they have a grievous and irremediable condition

 

d.

be satisfied that the request for medical assistance in dying was made in writing and signed and dated by the client or by their proxy before two independent witnesses, who then also signed and dated the request

 

e.

ensure that the client has been informed that they may, at any time, and in any manner, withdraw their request

 

f.

ensure that another assessor (physician or nurse practitioner) provided a written opinion that the client meets all of the eligibility criteria established for medical assistance in dying

 

g.

be satisfied that they and the other assessor are independent

 

h.

ensure that there are at least 10 days between the day on which the request was signed21 by or on behalf of the client and the day on which medical assistance in dying is provided, or if both assessors are of the opinion that the client’s death or loss of capacity to provide informed consent is imminent, any shorter period that the medical assessors consider appropriate to the circumstances

12.

Immediately before providing medical assistance in dying, the nurse practitioner acting as an assessor-prescriber must give the client an opportunity to withdraw their request and ensures that the client gives express consent to receive medical assistance in dying.

13.

Nurse practitioners acting as an assessor-prescriber, who prescribe22 or administer the substances to be used in medical assistance in dying, must do so in the client’s name, on the pre-printed provincial prescription, and document on the prescription that the indication is medical assistance in dying.

14.

The nurse practitioner acting as an assessor-prescriber must receive the substances for medical assistance in dying directly from the dispensing pharmacist.

15.

Nurse practitioners acting as an assessor-prescriber must personally attend the client during the self-administration or personally administer the substances for medical assistance in dying, and must remain in attendance until death is confirmed. This responsibility must not be delegated or assigned to any other person.

16.

Nurse practitioners acting as an assessor-prescriber are responsible for completing the medical certificate of death. The medical certificate of death must indicate that the manner of death involved medical assistance in dying and that the cause of death is the underlying illness/disease causing the grievous and irremediable medical condition.

17.

Nurse practitioners comply with information or medical record requests made by a provincial agency tasked with a review of medical assistance in dying.

18.

Nurse practitioners comply with reporting requirements established for the oversight or monitoring of MAiD. The required information must be submitted to the BC Ministry of Health using the applicable provincial forms and within the established timeframes for reporting23.

19.

Nurse practitioners administering the medical assistance in dying substances complete the Provincial Medication Administration Record and retain it as part of the medical record. Additionally, nurse practitioners are responsible for returning to the pharmacy any unused substances as soon as reasonably practicable, within 72 hours of confirmation of the client’s death. This responsibility must not be delegated or assigned to any other person.

Notice: March 27, 2020. Effective immediately and for the duration of the COVID-19 public health emergency in British Columbia, the requirement that nurse practitioners must not delegate or assign the return of MAiD substances to any other person is temporarily subject to the following exception: A nurse practitioner may ask another physician, nurse practitioner, licensed practical nurse, registered nurse, registered psychiatric nurse or pharmacist to return the substances to the pharmacy. The nurse practitioner must document the name of the person assigned to return the substances in the client record.

20.

Nurse practitioners must ensure the following information is present in the client’s medical record:

 

a.

copies of all relevant medical records from other medical practitioners/ health care professionals involved in the client’s care supporting the diagnosis and prognosis of the client’s grievous and irremediable condition, disease or disability; this includes ensuring that a specialist has provided a diagnosis and prognosis, including treatment recommendations, and that this has been discussed with the client by the specialist

 

b.

documentation of all requests for medical assistance in dying with a summary of the discussion

 

c.

confirmation that the assessor-prescriber and the second assessor discussed and determined which practitioner would prescribe and/or administer the substance used for medical assistance in dying

 

d.

confirmation by the assessor-prescriber that all the requirements have been met including the steps taken and the substance prescribed

 

e.

confirmation that after the completion of all documentation, and just prior to administration, the client was offered the opportunity to withdraw the request

21.

Nurse practitioners must use and follow the applicable provincial forms, guidelines, and pre-printed provincial prescription specific to medical assistance in dying.

Footnotes

21

The Criminal Code requires 10 "clear days" from the valid request to the procedure. The day the request is signed in a valid manner is Day 0 and the day of the procedure is Day 11; the 10 days are the days between those points. "Signed in a valid manner" means that the request is: made in writing and signed by the person or a proxy; signed and dated after the person was informed they had a grievous and irremediable condition; and signed and dated in the presence of two independent witnesses, who meet the conditions in the Criminal Code.

22

When prescribing substances for MAiD, nurse practitioners also follow the Prescribing Drugs standards, limits, and conditions found in Part F, including the limits and conditions on controlled drugs and substances.

23

Timeframes for reporting are dependent on the information being submitted. Refer to the BC Ministry of Health Medical Assistance in Dying website for more information.

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