12 Jan Medical Assistance in Dying in Canada: Assessors Discuss Eligibility Decision Making
MedicalResearch.com Interview with:
Dr. Thorne
Sally Thorne RN, PhD, FAAN, FCAHS, FCAN, CM
Professor Emeritus, School of Nursing
Co-Principal Investigator with :
Dr. Pesut
Dr. Barbara Pesut PhD, RN
Professor in the School of Nursing
Principal Research Chair in Palliative and End of Life Care
University of British Columbia
MedicalResearch.com: What is the background for this study?
Response: Medical assistance in dying (MAiD) was legalized in Canada in June of 2016 for Canadians who were facing a reasonably foreseeable natural death and met an explicit set of eligibility criteria as determined by qualified health care providers (physicians or nurse practitioners). In 2021, the legislation was extended to include the possibility of MAiD for persons who were suffering from a ‘grievous and irremediable’ medical condition but for whom natural death was not immediately foreseeable. As assisted dying represented a significant change in available options for Canadians with terminal or chronic conditions, requiring significant practice adaptations and including numerous legal, social, ethical, moral implications, the health research community has been working in consultation with clinicians, service providers and governments to generate knowledge that ensures safe, ethical and equitable practice in this regard.
MedicalResearch.com: Would you describe the assessment process for Track 2 medical assistance in dying?
Response: Track 2 MAiD assessment – assessment of those applicants for whom natural death is not immediately foreseeable – involves a considerably more complex and extensive processes for assessors to determine whether an applicant is or is not eligible under Canadian law. As with Track 1 cases (cases in which natural death is understood to be reasonably foreseeable), it begins with a signed and witnessed written request by the applicant, followed by determinations by two independent assessors that the applicant meets all eligibility criteria and documentation of those determinations. Although each case is assessed on an individual basis and takes all relevant circumstances into account, the assessor must confirm that the applicant is eligible for health services funded by a province or territory, or the federal government; at least 18 years old and mentally competent; has a grievous and irremediable medical condition; has made a voluntary request for medical assistance in dying; and has given informed consent. The legislation provides further guidance for what constitutes a grievous and irremediable medical condition, and what information an applicant requires in advance of a consent being considered informed.
In addition to confirming that an applicant meets all of the above criteria, cases that are deemed “Track 2” (where natural death is not reasonably foreseeable), require a mandatory 90-day assessment period (unless there is an immediate risk of losing capacity to consent), and a number of additional aspects to the assessment. One of the two medical practitioners who provides an assessment must have expertise in the medical condition that is causing the unbearable suffering; the applicant must be informed of available means to relieve the suffering, and offered consultations with professionals who provide services including, where appropriate, palliative care, community services, counselling services, mental health and disability support services; and all reasonable and available means to relieve the suffering have been discussed with the applicant and reasonably considered. We designed our study to help health care practitioners, system leaders, and the Canadian public better understand the complexity of the process of assessment and decision making to determine eligibility for Track 2 MAiD in Canada.
MedicalResearch.com: What are the main findings?
Response: What we found was that assessors needed to begin by getting to know the person making the request and the context for their request. This required developing as trusting a relationship as possible (understanding that many of these individuals with chronic conditions may have developed distrust in the health care system by virtue of longstanding efforts to seek help over time). In order to understand the nature of the suffering that had led to the request, assessors needed to hear from the patient’s perspective what the experience of illness or disability had been for them. In many cases, developing a comprehensive record of the medical and care history was a complex and time-consuming process. Within this process, they needed to make a determination as to whether the applicant’s case best fit the criteria for Track 1 or Track 2. Canadian law does not place a specific timeframe on the matter of reasonably foreseeable natural death, so clarity was required on the medical diagnoses and their projected trajectories of decline toward death in order to determine which set of eligibility criteria and safeguards were most appropriate to each situation. As applicants may have had multiple medical diagnoses and projected timelines are difficult to determine with any certainty, assessors described some of the many factors they might take into consideration in weighing the decision as regards Track designation and whether the 90-day waiting period was required.
Assessors also needed to determine mental capacity to be making a weighty decision such as requesting MAiD, and to be confident that the decision to request MAiD was being made on a voluntary basis, and not affected by undue influence from other people or circumstances that might be exerting pressure on the applicant’s perceived options. They described various ways in which they managed their encounters with applicants so as to be able to determine with some certainty that these were volitional and informed requests and that applicants fully understood the nature of the application. Where there was any hesitation about these issues, they described ways they had worked out to surface the information and come to the decisions that were necessary to determine whether the applicant was or was not eligible.
In terms of suffering, assessors understood their obligation not to be one of judging the applicant’s degree of suffering but rather trying to understand the nature of it from the applicant’s perspective, so that they could determine what might constitute reasonable means to alleviate that suffering and whether applicants had had access to those options. This required a very detailed understanding of the individual circumstances of an applicant’s life, including any barriers the applicant may have had to seeking or accepting treatment or care, and the values that helped shape what each applicant considered reasonable in terms of illness management. They needed to document prior efforts to seek treatment or supports, any difficulties with the health care system in terms of access intervention, and make a determination as to whether any refusals to accept care that had been offered were reasonable given that particular applicant’s circumstances, experiences or values.
The entire process of the 90-day (and often much longer) assessment process was onerous for assessors given the volume of documentation that must be reviewed and understood and the depth of understanding that was required in order to come to an eligibility decision. Applicants were often frustrated or impatient with delays, and in cases in which they were found ineligible, assessors expressed concern about the risks with respect to their heightened distress.
Many assessors found it helpful to be actively involved in consultation with other clinical colleagues during this process in order to ensure that they were as comprehensive as necessary in the information upon which they were basing their decision, and their ability to navigate what were often highly complex assessments.
MedicalResearch.com: What should readers take away from your report?
Response: Health care professionals who determine MAiD eligibility in Canada take that responsibility very seriously. Track 2 cases in particular require an enormous investment of time and effort, engaging in a meaningful relationship with the applicant over time, and considerable deliberation and reflection to ensure that the basis for determination of eligibility criteria is well understood, accurately documented, and consistent with accepted practice. Because of the clinical, social, ethical and legal complexities such cases entail, health care professionals who engage in this work may do so at some risk to their own psychological and professional well-being.
MedicalResearch.com: What recommendations do you have for future research as a results of this study?
Response: It is important that a robust body of knowledge be available to guide this complex practice so as to ensure its integrity, alignment with the intentions of the legislation, standards of professional practice, and the values of Canadians. Research grounded in the highly informed perspectives of those who engage in this work is particularly needed to help us understand the nuances and challenges of this practice, and to develop the kinds of informational and peer supports that will ensure ongoing integrity, dignity and safety of Canadians.
Disclosures: Our research has been funded by the Canadian Institutes of Health Research. We have no other financial disclosures or conflicts of interest to declare.
Citation:
—-
The information on MedicalResearch.com is provided for educational purposes only, and is in no way intended to diagnose, cure, or treat any medical or other condition.
Some links may be sponsored. Products are not warranted or endorsed.
Always seek the advice of your physician or other qualified health and ask your doctor any questions you may have regarding a medical condition. In addition to all other limitations and disclaimers in this agreement, service provider and its third party providers disclaim any liability or loss in connection with the content provided on this website.
Last Updated on January 12, 2026 by Marie Benz MD FAAD