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Quebec's Advance Request for MAiD

Understanding how Quebec is pioneering patient autonomy in end-of-life care

Understanding Advance Requests for MAiD

An Advance Request allows a person diagnoses with serious and incurable illnesses that is expected to lead to a loss of capacity, like dementia, to provide consent in advance to receive Medical Assistance in Dying (MAiD) after they lose capacity. This groundbreaking Quebec law addresses a critical gap in end-of-life care.

Specific criteria must be met both to make an Advance Request and to receive MAiD after capacity is lost. This ensures the process remains ethical, legal, and aligned with patient wishes while maintaining appropriate safeguards.

Federal MAiD Eligibility Criteria

Understanding federal eligibility requirements is crucial, as these must still be met when an Advance Request is used. The key difference lies in the timing of when criteria must be fulfilled during the illness journey.

Serious Illness

Have a serious and incurable illness, disease, or disability

Decision Capacity

Be capable of making health care decisions for yourself

Informed Consent

Give informed consent to receive MAiD

Advanced Decline

Be in an advanced state of decline that cannot be reversed

Unbearable Suffering

Experience unbearable physical or psychological suffering that cannot be relieved under acceptable conditions

Why Advance Requests Are Needed

A person with dementia may not meet MAiD eligibility criteria early in their disease. However, as their illness progresses to the point where they meet the criteria, they might lack the capacity to consent to receive MAiD. This situation would exclude individuals from accessing MAiD solely due to the nature of their illness.

Quebec's Advance Request for MAiD aims to address this exclusion, potentially protecting the Canadian Charter right to life, liberty, and security of person (section 7).

1

Early Diagnosis

Patient has capacity but doesn't meet suffering criteria

2

Disease Progression

Symptoms worsen, approaching unbearable suffering

3

Lost Capacity

Patient meets suffering criteria but can no longer consent

4

Advance Request Solution

Prior consent allows MAiD to proceed ethically

Paul's Journey: A Case Example

The Challenge

Paul has just been diagnosed with dementia and is showing early signs such as forgetting names, having difficulty finding words, and misplacing items. While these symptoms are distressing, they likely don't place Paul in an advanced state of decline or cause unbearable suffering.

If Paul were to wait until he was in an advanced state of decline and experiencing unbearable suffering, he would be at high risk of losing the ability to make healthcare decisions or having the capacity to consent to MAiD. In either scenario, Paul would not be eligible for MAiD.

This is why an Advance Request is crucial for individuals like Paul.

Quebec's Advance Request for MAiD: The Process

01

Receive Diagnosis

Paul receives a diagnosis of dementia, meeting the "serious and incurable illness" criterion while still retaining decision-making capacity.

02

Complete the Request

With support from a physician or specialized nurse practitioner, Paul completes an Advance Request, describing in detail what manifestations of dementia he would consider unbearable suffering.

03

Designate Trusted Person

Paul may designate one or two Trusted Third Persons to ensure his wishes are known and respected, and to notify healthcare professionals when criteria are met.

04

Sign and Submit

The Advance Request is signed by Paul, the physician or specialized nurse practitioner, two witnesses (or a notary), and any Trusted Third Persons, then submitted to the provincial registry.

Important Points to Remember

Medical Recognition

The suffering described in the Advance Request must be medically recognized as suffering that can result from the specific illness.

Observable Criteria

The suffering described must be objectively observable by a physician or specialized nurse practitioner.

Not Automatic

An Advance Request will not automatically lead to the administration of MAiD. Multiple assessments and criteria must be met.

Modifiable

The request may be modified, edited, or cancelled at any time, as long as the person has the decision-making capacity to do so.

Registry Storage

The Advance Request will be stored in a provincial registry, accessible by members of the healthcare team.

When Capacity Is Lost: The Assessment Process

Four years after making his Advance Request, Paul's illness has progressed to the point where he has lost the ability to make medical decisions for himself. Here's what happens next:

Capacity Loss Identified

A healthcare professional or Trusted Third Person recognizes Paul has lost capacity. They consult the provincial registry and find he has made an Advance Request for MAiD.

Notification Process

All Trusted Third Persons listed in the Advance Request are notified of Paul's loss of capacity.

Suffering Assessment

Trusted Third Person notifies healthcare professionals when Paul appears to be experiencing the suffering described in his request.

Medical Examination

A physician or specialized nurse practitioner examines Paul to determine if he objectively appears to be experiencing the suffering described in his Advance Request on a recurring basis.

Independent Review

A second independent physician or sNP assesses Paul. If both confirm criteria are met, Paul can receive an assisted death.

The Role of Trusted Third Persons

Critical Responsibilities

The Trusted Third Person plays a vital role in ensuring the patient's wishes are respected and acted upon appropriately. They are responsible for:

  • Making sure the patient's wishes expressed in the Advance Request are known and respected
  • Notifying healthcare professionals if they believe the patient has lost capacity to make medical decisions
  • Identifying when the patient is experiencing the suffering described in the Advance Request
  • Recognizing enduring and unbearable suffering that cannot be relieved under tolerable conditions

If no Trusted Third Person is designated or available, healthcare professionals can fulfill this notification role, ensuring the process can still proceed ethically.

Looking Forward: National Implications

Federal Support

The federal government has launched a national conversation about advance requests for MAiD and will not challenge Quebec's Bill 11.

Public Support

Advance requests for MAiD are widely supported by the Canadian public, reflecting a desire for greater autonomy in end-of-life care.

Ethical Safeguards

Quebec's law demonstrates that advance requests can be administered ethically and legally with appropriate safeguards in place.

Quebec's Advance Request for MAiD process is complex, but necessarily so to ensure ethical and legal administration. From our perspective, there seems to be no compelling argument against advance requests for MAiD, as long as appropriate safeguards are in place, and we may soon have advance requests for MAiD available across the country—a position widely supported by Canadians and one we fully endorse.