General Overview

• Identify what is important
• Explore, inform of alternative options (including palliative care), support
• Assure that you will continue to provide care they want
• Clarify that wishes can change at any time
• Refer if required

Federal Eligibility for MAiD

• Insured under Health Insurance Act
• 18 years of age and capable of making decisions with respect to their health;
• Grievous and irremediable medical condition;
  • Serious and incurable illness, disease or disability;
  • Advanced state of irreversible decline in capability;
  • As a result, they suffer enduring physical or psychological suffering that is intolerable to them and that cannot be relieved under conditions that they consider acceptable;
  • 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.
• Voluntary request for medical assistance in dying that was not made as a result of external pressure;
• 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

MAiD Process

Request of information

• First contact with health professional (may be physician)
  • Explore motives of the MAiD request
  • Provide information on
    • Illness
    • Medical diagnosis
    • Life expectancy (prognososis)
    • Possible alternative treatment options including curative and palliative
  • Discuss criteria for MAiD
    • Assess capacity to consent to care

Request for MAiD

• Patient must sign form in front of health professional and countersigned by health professional (MD, RN, SW, PT/OT, Psychotherapist)
  • Two witnesses are required
    • Must not be a beneficiary or part of the patient's health care team or establishment

Treating physician must be notified (if not yet)

• Medical decision by first physician must be made
  • Explore motives of the MAiD request, provide information (including palliative care) once again
  • Assess criteria for MAiD
  • Discussion with interdisciplinary team, patient, family

Support

• May ask for GIS (Groupe interdisciplinaire de soutien)
  • Team includes physician, nurse, ethicist, spiritual services, social worker, coordinator, psychologist
  • Guides throughout the steps of MAiD
  • Useful in difficult cases

Decision

• If physician has conscientious objections, must communicate to DSP to refer to another physician
• If the physician has no conscientious objections
  • Explain they are allowed to change their mind at any moment, even before injection
  • Patient must repeatedly state their desire for MAiD over multiple visits within a "reasonable" interval
• Must have independent second opinion from another physician

Non-admissible Request by First or Second physician

• Inform the patient of the refusal and the reasons for refusal
• Consider GIS
• Ensure that the patient is aware about recourse for "Commissaire local aux plaintes"
• Ensure that the patient is aware they they may submit another request

Admissible Request

• Determine location (eg. home, hospital)
• Determine moment
• Determine who the patient would want with them
• Contact pharmacist, discuss when to pick-up medication and protocol
• Discuss organ donation or tissue donation (referral to organ donation organization)

Pharmacological Considerations

• Good IV access is an absolute prerequisite
  • Consider central line if poor peripheral access
• Step 1: Anxiolysis
  • Midazolam 2.5-10mg IV over 2 minutes
• Step 2: Artificial Coma Induction
  • Lidocaine 2% (without epinephrine) 2mL IV over 30 seconds (or magnesium sulfate if allergy to lidocaine)
  • Propofol 1000mg IV over 5 minutes (or phenobarbital if allergy to propofol)
  • Coma confirmed prior to step 3
• Step 3: Neuromuscular blocker injection
  • NS 0.9% 10mL IV flush
  • Cisatracurium 30mg rapid IV injection (or rocuronium)
  • Repeat flush

Declaration of MAiD

• Death certificate (note: MAiD is NOT a cause of death)
• Send all documentation to CMDP/CMQ and Commission sur les soins en fin de vie