MAiD, Dementia, and Imperfect Solutions
Exploring the complex intersection of Medical Assistance in Dying and dementia in Canada. Can people with dementia access MAiD? What are the challenges, and what solutions exist?
Subscribe to MAiD in Canada
Can People with Dementia Have MAiD?
With Robert Munsch's recent MAiD eligibility news and the forthcoming federal report on advance requests, this topic demands attention. The question isn't simple: can someone have MAiD for dementia, and can someone have MAiD with dementia?
While the answer is technically yes to both, the reality is far more complex. This piece explores the particular challenges around MAiD eligibility in dementia, examining assessment approaches, the Waiver of Final Consent, Quebec's advance requests, and advance directives.

Key Insight
For mental illness, a person can have MAiD with a mental illness, but not for one—yet. For dementia, both are possible, but timing and capacity create significant barriers.
The Three Core Eligibility Criteria
Understanding MAiD eligibility for dementia requires knowing the three fundamental criteria that must all be met simultaneously:
Serious & Incurable Illness
The person must have a serious and incurable illness, disease, or disability.
Advanced Irreversible Decline
They must be in an advanced state of irreversible decline in capability.
Intolerable Suffering
They must experience enduring, intolerable physical or psychological suffering that cannot be relieved by acceptable means.
The challenge with dementia is that these criteria are rarely all met at the same time while the person retains decision-making capacity.
The Dementia Dilemma: A Matter of Timing
Early Stage
Meets criterion #1 (serious illness) but typically not #2 (advanced decline) or #3 (intolerable suffering). Person has capacity but isn't eligible yet.
Moderate Stage
The critical window. May meet all three criteria during periods of clarity and capacity. This stage can last years with unpredictable decline.
Advanced Stage
Meets all three criteria but person has typically lost the capacity to consent. Cannot participate in the MAiD assessment process.
"Cognitive decline is inherently unpredictable. It can be gradual or stepwise, and there is no clear moment when a person suddenly and completely loses decision-making ability."
Early Dementia: Signs and Challenges
Memory & Cognition
Memory loss, planning difficulties, confusion about time or place, and problems with familiar tasks emerge early.
Communication Changes
New problems with words in speaking or writing, trouble understanding visual or spatial relationships.
Behavioral Shifts
Decreased judgment, social withdrawal, misplacing things, and mild changes in mood or personality.
While these symptoms are distressing, they typically don't constitute the "intolerable suffering" or "advanced decline" required for MAiD eligibility. This creates a painful paradox: diagnosis comes early, but eligibility comes much later.
Two Assessment Approaches
MAiD assessors may use different frameworks to determine eligibility for people with dementia. Neither is perfect, and the appropriate approach depends on individual circumstances.
"10 Minutes to Midnight"
Focuses on the critical window just before capacity loss. When someone is clearly approaching that moment, their imminent loss of decision-making ability means they're in an advanced state of decline. Requires precise timing and continuous monitoring.
Cumulative Decline
Looks at the entire constellation of symptoms and suffering. The combination of memory loss, personality changes, physical limitations, and cognitive decline collectively meets the threshold—independent of imminent capacity loss. Emphasizes overall impact.
The Continuous Care Challenge
Both assessment approaches depend heavily on consistent medical oversight. The "10 minutes to midnight" approach especially requires a professional who knows the person well enough to recognize when that critical threshold has been reached.
But many Canadians lack consistent access to primary care. Fragmented care makes it much harder to determine eligibility timing, creating yet another barrier that disproportionately affects vulnerable populations.
6.5M
Canadians Without Primary Care
Lack consistent medical oversight for complex assessments
Imperfect Solutions: Waiver of Final Consent
Before 2021, people had to give explicit consent immediately before MAiD. Audrey Parker's advocacy changed this, introducing the Waiver of Final Consent—but it has significant limitations for dementia.
1
The Problem Before 2021
People like Audrey Parker faced an impossible choice: die earlier than desired to ensure capacity for final consent, or risk losing capacity and suffering longer.
2
Audrey's Amendment
Introduced the Waiver of Final Consent for Track 1 patients at risk of losing capacity. Allows setting a future date without requiring final consent if capacity is lost before then.
3
Limitations for Dementia
Only applies after eligibility is established. Requires choosing a specific date. Doesn't extend indefinitely. Not designed for the years-long progression of dementia.
Quebec's Advance Request Model
Quebec separates MAiD eligibility determinations over time, allowing people with early dementia to pre-specify intolerable conditions and file advance requests. When those conditions manifest years later, assessors determine if the current situation matches what was described.
How It Works
File advance request specifying future intolerable manifestations. Request stored in provincial repository. Retrieved when conditions manifest.
The Promise
Addresses timing problem. Allows decisions while capacity exists. Preserves prior explicit wishes for future use.
The Challenges
Provider reluctance without prior relationship. Document interpretation difficulties. "Pleasantly confused" dilemma. Conscientious objection rights. Limited real-world experience.
"Quebec's model is a meaningful attempt to square the realities of progressive cognitive decline with a person's prior wishes. But it might replace one set of problems with another."
Looking Forward: What Comes Next
The federal government's report on advance requests is expected any day. Public polling shows overwhelming support, but implementation requires political will against vocal opposition.
84%
Canadian Support
Favor advance requests for MAiD, particularly for dementia
Important Distinctions
  • Advance Directives: Cannot currently be used to request MAiD in Canada, despite being valid for other end-of-life decisions
  • Substitute Decision-Makers: Can make many medical decisions but cannot legally consent to MAiD on behalf of someone who lacks capacity
  • The Path Forward: Requires conversations with ourselves, each other, our MPs, and our federal government about what kind of access we want to provide