Medical Assistance in Dying in Canada – Extract from First Annual Report on 2019

Highlights of Medical Assistance in Dying in Canada (MAID)

This report contains information collected from practitioners and pharmacists for the 2019 calendar year on written requests for and cases of MAID across Canada. The data presented has primarily been drawn from the federal monitoring system for MAID, which was launched on November 1, 2018. Prior to that date, data was provided voluntarily by provinces and territories (June 17, 2016 to October 31, 2018) which has supplemented some of the analyses presented here.

The report is the outcome of significant collaboration between federal, provincial and territorial levels of government, and provides the most comprehensive portrait of MAID in Canada to date. Future reports using data through the federal monitoring system will build on these analyses to provide an understanding of trends related to requests for, and the delivery of, MAID over time.

The number of medically assisted deaths is steadily increasing

In 2019, there were 5,631 cases of MAID reported in Canada, accounting for 2.0% of all deaths in Canada.

The number of cases of MAID in 2019 represents an increase of 26.1% over 2018 numbers, with all provinces experiencing a steady year over year growth in the number of cases of MAID since its introduction into law in 2016.

When all data sources are considered, the total of number of medically assisted deaths reported in Canada since the enactment of federal legislation is 13,946.

Profile of MAID recipients

In 2019, the proportion of men and women receiving MAID across Canada was nearly equal with only slightly more cases among men (50.9%) than women (49.1%).
The average age of persons who received MAID in Canada was 75.2 years; this average age varied across jurisdictions ranging from a low of 70.4 in Newfoundland and Labrador to a high of 76.9 in British Columbia.
Over 80% of MAID deaths occur at age 65 or older.
Cancer (67.2%) was the most commonly cited underlying medical condition of persons who received MAID, followed by respiratory (10.8%) and neurological (10.4%) conditions.
The majority of MAID recipients also received supportive services

The majority of persons receiving MAID (82.1%) were reported to have received palliative care services.
Of those MAID recipients who did not access palliative care services prior to receiving MAID, the majority (89.6%) had access to these services but chose not to do so, according to the reporting practitioner.
Among the 41.3% of patients requiring disability support services, 89.8% had received them.
MAID is most often provided in a home or hospital setting by primary care physicians

The primary settings for the administration of MAID are hospitals (36.3%) (excluding palliative care beds/units) and patients’ private residences (35.2%). The remaining cases of MAID occurred in palliative care units (20.6%) and residential care (6.9%) or other settings (1.0%).
There were 1,271 unique practitioners who provided MAID in 2019. MAID was provided most frequently by family medicine physicians (65.0%), followed by palliative medicine specialists (9.1%) and anesthesiologists (5.0%).
Nature of suffering among MAID recipients

Practitioners reported that suffering among MAID recipients was closely tied to a loss of autonomy.
Loss of ability to engage in meaningful life activities (82.1%) followed closely by loss of ability to perform activities of daily living (78.1%), and inadequate control of symptoms other than pain, or concern about it (56.4%) were the most frequently reported descriptions of the patient’s intolerable suffering.
One-quarter of written requests for MAID did not result in an assisted death

There were 7,336 written requests for MAID reported through the MAID monitoring system in 2019. Of these requests, 26.5% (or 1,947) did not result in a MAID death, because the patients died before receiving MAID (57.2% or 1,113 cases), were deemed ineligible (29.3% or 571 cases), or they withdrew their request (13.5% or 263).

The most frequently reported reasons why a person was deemed ineligible for MAID (7.8% of written requests) were: lack of capacity to make health care decisions (32.2%); the individual’s natural death was not reasonably foreseeable (27.8%); and the individual was not in an advanced state of irreversible decline in capability (23.5%).

Of those persons who were assessed as eligible for MAID, but did not receive it, the majority died of another cause prior to administration (15.2%), while a small number (3.6%) of persons withdrew their request after having been deemed eligible.

This first report using data collected under Canada’s new monitoring and reporting system represents the collaborative efforts of federal, provincial and territorial governments and healthcare professionals to provide a comprehensive picture of the administration of MAID across the country.

MAID is being delivered across the country as part of the suite of publicly available health care services. Provinces and territories have established information lines and care coordination services to facilitate MAID requests and connect interested individuals to participating clinicians. Training and guidance material for health professionals continue to develop and evolve. The Canadian Association of MAID Assessors and Providers (CAMAP), the first organization of its kind in North America, has been established and is supporting a network of health professionals assessing and providing MAID. In addition, bereavement support services addressing the unique circumstances for family and friends of individuals receiving MAID are emerging. Academics are collaborating with clinicians to produce much needed research on the MAID experience, so we know where improvements are required.

MAID is a complex issue on which Canadians have strong opinions that are deeply rooted in personal values and individual circumstances. I have heard many heart-warming stories from Canadians describing how MAID granted their loved ones a calm, compassionate and peaceful ending surrounded by family and friends. Clinicians have expressed how honoured they feel to participate in an experience that is so intimate and personal, which they often describe as one of the most rewarding aspects of their practice.

The federal Regulations for the Monitoring of Medical Assistance in Dying came into force on November 1, 2018, setting out new enhanced reporting requirements for standardized data collection across the country. Since that time, Health Canada has been working in partnership with Statistics Canada, provinces and territories, as well as physicians, nurse practitioners and pharmacists to support reporting through this new system. The collection of robust, nationally comparable data not only enables reporting on MAID’s implementation, but also contributes to an evidence base important to future discussions on MAID – both in response to recent court cases and through a statutory review of the legislation that is required under Bill C-14.

As we move forward, I (Minister) expect this collaborative work to continue in the context of upcoming changes to the federal MAID legislation. I was pleased to work with the Minister of Justice and Attorney General of Canada and the Minister of Employment, Workforce Development and Disability Inclusion, in tabling amendments to Canada’s MAID legislation, in response to the September 2019 Superior Court of Quebec ruling in Truchon, a challenge to Canada’s 2016 MAID law launched by Nicole Gladu and Jean Truchon. The changes proposed by our Government were informed by broad consultations, including a series of roundtable discussions with health care professionals, regulatory bodies and other key stakeholders, as well as an online survey of Canadians that garnered over 300,000 responses.

In response to Truchon, the proposed legislation (Bill C-7) would see the removal of the requirement for an individual’s death to be reasonably foreseeable, allowing persons who are suffering intolerably, but who are not dying, to be eligible for MAID if all other criteria have been met. It would also implement other changes to address barriers to access noted by healthcare professionals and other experts during the roundtable discussions. Following passage of the Bill, the MAID monitoring regulations would be amended to align with the legislative changes to support even stronger monitoring and reporting.

The information released in this first annual report is a critical body of knowledge for Canadians about MAID. I encourage you to review the data, consider the findings, and continue the dialogue.

— The Honourable Patty Hajdu, Minister of Health

Introduction

Nearly all countries that permit some form of medically assisted dying consider public reporting to be a critical component to support transparency and foster public trust in the application of the law. The need for the consistent collection of information and public reporting also reflects the seriousness of MAID as an exception to the Criminal Code prohibition against the intentional termination of a person’s life.

Canada’s federal MAID legislation, Bill C-14, An Act to Amend the Criminal Code and to Make Related Amendments to Other Acts (Medical Assistance in Dying) was enacted on June 17, 2016. In addition to establishing eligibility criteria for MAID and safeguards for its application, the legislation also required the federal Minister of Health to make regulations to support data collection and reporting on both requests for, and the provision of, MAID. The Regulations for the Monitoring of Medical Assistance in Dying came into force on November 1, 2018.

This document marks the first report using data collected under the new federal monitoring and reporting system established through these Regulations. This system is contributing to a better understanding of requests for MAID by providing insight into the circumstances under which MAID is requested and administered, along with information about the written requests for MAID that do not result in a medically assisted death.

Public Debate on Assisted Dying in Canada

While Canada’s federal legislation on MAID is relatively new, it is the outcome of years of public dialogue and debate. The issue of physician assisted dying first gained widespread attention in Canada during the early 1990s, when Sue Rodriguez, a woman living with amyotrophic lateral sclerosis (ALS), applied to the Supreme Court of British Columbia to have the Criminal Code prohibition on assisted suicide declared unconstitutional. The case was ultimately appealed to the Supreme Court of Canada (SCC), which ruled by a narrow (5-to-4) majority that the prohibition against assisted suicide was not in violation of the Canadian Charter of Rights and Freedoms (the Charter). At the time of the decision, no jurisdiction in the world had legalized medically assisted dying.

Nearly two decades later, in 2011, two family members of Kay Carter (a woman with spinal stenosis who sought and received an assisted death in Switzerland), William Shoichet (a physician willing to perform assisted suicide), and Gloria Taylor (a woman with ALS), along with the British Columbia Civil Liberties Association, once again challenged the federal Criminal Code provisions that prohibit a medical practitioner from aiding a person to die by suicide by providing them with the necessary medication, or from directly causing their death at their request. Similar to the Rodriguez case, the plaintiffs challenged the prohibition based on rights set out in sections 7 and 15(1) of the Charter.

In February 2015, the SCC rendered a unanimous (9-0) judgement in favour of the plaintiffs in the Carter case, declaring the challenged provisions of the Criminal Code void insofar as:

They prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life; and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition.

The judgement was not prescriptive about eligibility criteria for physician assisted dying beyond the specifics of the Carter case, and made “no pronouncement on other situations where physician-assisted dying may be sought”, and found that risks to vulnerable persons could be mitigated through carefully designed and monitored safeguards.

The SCC suspended the judgement for one year to allow time for the federal government to develop legislation and regulations. During this period, a federal election resulted in a new government, who requested a six-month extension of the suspension. An extension of four months was granted.

At the same time the Carter case was underway, the Government of Quebec had launched a series of expert panels and reports on end-of-life care, including discussions of physician assisted dying. As a result of these studies and public opinion research indicating broad support for euthanasia in certain circumstances, in 2014, the Quebec government passed An Act Respecting End-of-Life Care which set out the parameters for the provision of medical aid in dying to persons at the end of life. It also established a Commission on End-of-Life Care (la Commission sur les soins de fin de vie) to examine all matters relating to end-of-life care and oversee the application of specific requirements pertaining to assisted dying. This provincial legislation came into effect in December 2015.

The Development of Canada’s Legislation on MAID

At the time of the Carter decision in 2015, only a few other jurisdictions permitted assisted dying, including four U.S. states (Oregon, Washington, Vermont, and California), the country of Colombia, and the Benelux countries (Belgium, the Netherlands and Luxembourg).

International regimes were studied closely in the development of Canada’s legislation on MAID. There were a number of similarities in the legislative approaches taken by different jurisdictions, particularly with respect to safeguards. However, there were also significant differences in terms of which forms of assisted dying are permitted, and under what circumstances a person may be deemed eligible.

For example, in the U.S. states that permit assisted dying, eligibility is limited to persons who have a terminal illness (usually defined as being within the last 6 months of life) and only assisted suicide (i.e., self-administration) is permitted. In contrast, the Benelux countries determine eligibility, among other criteria, on the basis of whether the person is experiencing intolerable physical or psychological suffering resulting from a serious and incurable medical condition, rather than proximity to death. The Benelux countries also allow voluntary euthanasia (i.e., clinician administered), which is far more common than assisted suicide in these jurisdictions.

Following a period of extensive study and consultation, in April 2016, the federal government tabled Bill C-14 which proposed amendments to the Criminal Code to allow physicians and nurse practitioners to provide a medically assisted death in accordance with specified eligibility criteria and safeguards. While the legislation drew from other international regimes, it represented a uniquely Canadian approach. List 1.2: Bill C-14 Eligibility Criteria and Safeguards outlines Canada’s current MAID eligibility criteria and safeguards as per Bill C-14. Precise wording and additional details are available on the Health Canada MAID website.

Similar to the Benelux countries, both assisted suicide and voluntary euthanasia were permitted under Bill C-14. Under the Criminal Code amendments, medical assistance in dying “MAID” is an umbrella term which includes:

the administration by a medical practitioner or nurse practitioner of medication that will cause a person’s death at their request (clinician administered); and
the prescription or provision by a medical practitioner or nurse practitioner of medication that a person can self-administer to cause their own death (self-administered).
Unlike the Benelux countries, C-14 limited eligibility to competent adults whose “natural death was reasonably foreseeable”. However, the requirement that natural death be reasonably foreseeable provided more flexibility than jurisdictions requiring a specific prognosis (i.e., 6 months).

 Bill C-14 Eligibility Criteria and Safeguards

Eligibility Criteria

• Request MAID voluntarily (self-request only)
• 18 years of age or older
• Capacity to make health care decisions
• Must provide informed consent
• Eligible for publicly funded health care services in Canada
• Diagnosed with a “grievous and irremediable medical condition,” where a person must meet all of the following criteria:
  serious and incurable illness, disease or disability
  advanced state of irreversible declinein capability,
  intolerable physical or psychological suffering,
  natural death has become reasonably foreseeable

Safeguards

• Request must be in writing after the person is informed of grievous and irremediable condition
• Written request must be witnessed and signed by 2 independent witnesses
• 2 independent practitioners must confirm eligibility criteria are met
• Patient must be made aware of all treatment options available, including palliative care, in order to provide informed consent
• Practitioner must confirm request has been made freely, without undue influence
• 10 clear day reflection period unless death or loss of capacity is imminent
• Final confirmation and consent at time of administration or provision of the medication or prescription for self- administration

During the debate on Bill C-14, some Canadians and Parliamentarians voiced support for a more expansive regime, which would allow advance requests, and expand eligibility to mature minors and persons whose sole underlying medical condition is a mental illness. Given the complexity of the issues raised, uncertainty around how such a regime could be implemented in the Canadian context, and the need to pass legislation under compressed timelines, Parliament agreed to refer these particularly complex issues for further study, with the findings to be tabled within 2 years of the reviews being initiated.

The Council of Canadian Academies (CCA) was selected by the federal government to undertake independent reviews on these issues, which were finalized in December 2018. The reports and a summary are available on the CCA’s website.

The legislation also required that its provisions, as well as the state of palliative care, be referred to one or more parliamentary committees for review in the fifth year after the Act received Royal Assent (2020).

Finally, the federal legislation on MAID obligated the federal Minister of Health to make regulations to support data collection and reporting on both requests for, and the provision of, MAID. Federal Regulations for the Monitoring of Medical Assistance in Dying, which specify reporting requirements for practitioners and pharmacists, came into force and a new Pan-Canadian Data Collection portal was launched on November 1, 2018. The majority of the information provided in this report is based on the data collected under this monitoring system.

Implementation of MAID Across Canada

Following the passage of federal MAID legislation, provinces and territories had the challenging task of adapting their health care systems within a short time frame to allow for consistent and safe access to this service. While the Criminal Code, which applies across Canada, establishes the eligibility criteria that must be met and safeguards that must be complied with before MAID is provided, it is the provinces and territories that are responsible for the delivery of health care services and the administration of justice. As such, each jurisdiction has taken its own approach to the organization and delivery of MAID.

For example, in Newfoundland and Labrador, Nova Scotia, New Brunswick, and British Columbia regional health authorities play a central role in the coordination of MAID, including supporting patients and providers who need assistance in navigating the service. Meanwhile, some provinces, such as Manitoba, Saskatchewan, and Alberta have set up province-wide care MAID coordination systems to triage the intake of MAID requests, support patient information/access, help connect clinicians and streamline reporting. Smaller jurisdictions (e.g., Northwest Territories) typically have less formal systems set up primarily to support patients in connecting with a willing MAID provider.

With respect to oversight, some jurisdictions, such as Manitoba, Saskatchewan, Alberta, and British Columbia have implemented review committees to ensure MAID is being provided in accordance with federal and provincial rules. In Ontario, all MAID deaths are reported to the Chief Coroner’s Office who is also responsible for oversight. The regulatory bodies for medicine, nursing and pharmacy in each province and territory are also responsible for promoting the lawful practice of MAID and ensuring that health professionals act in accordance with principles of professional conduct and established standards of care.

Several provinces have been reporting publicly on MAID outside of the federal monitoring system. For example, Nova Scotia, Quebec (through its arms-length commission) and Alberta regularly publish provincial-level data. Independent groups/research organizations and media have also published MAID data from across the country which have been obtained directly from provincial, regional or institutional sources. Health Canada has collaborated with all jurisdictions to support accuracy of reporting and coherence with provincially published data for the total number of MAID deaths.

 Methodology and Limitations

As noted earlier, the federal legislation on MAID required the Minister of Health to make regulations to establish a federal monitoring regime to collect data relating to MAID in Canada. Health Canada worked closely with the provinces and territories, and consulted practitioners, pharmacists and other stakeholders in the development of the monitoring regime. The objective of this process was to create a reporting system that captured the elements required under the legislation without placing undue reporting or administrative burden on practitioners or duplicating existing systems.

 Data Collected Under the Federal Regulations

Under the Regulations, physicians and nurse practitioners are required to report on all written requests for MAID, even if the request does not result in the administration of MAID.

There are six possible outcomes for which a practitioner must provide a report (as per the Guidance for reporting on medical assistance in dying):

• MAID is provided by a practitioner via administration of a substance
• MAID is provided by a practitioner via the prescribing or provision of a substance to a patient for the purpose of self-administration
• The patient is referred or transferred as a result of their written request
• The patient is found ineligible for MAID
• The practitioner becomes aware that the patient has withdrawn their request for MAID
• The practitioner becomes aware that the patient has died from a cause other than MAID
• Pharmacists are required to report on the preparation and dispensing of substances in connection with the provision of MAID.

Practitioners also report:

basic sociodemographic information about the person requesting MAID (e.g., age, gender, postal code);
on the assessment of the request and whether eligibility requirements were met (e.g., underlying medical condition, description of suffering);
information about procedural safeguards if MAID was provided (e.g., 10-day reflection period, two practitioners confirm eligibility); and,
information as to why a request may have gone unfulfilled.
A complete list of the information that must be provided by practitioners and pharmacists under the Regulations can be found on Health Canada’s website.

Practitioner and pharmacist reporting under the monitoring system occurs in two ways: to a designated provincial or territorial body, or, directly to Health Canada. Some provinces and territories have a designated recipient (DR) listed in the Regulations. These are organizations that are responsible for collecting MAID information directly from practitioners and pharmacists in their jurisdiction and reporting this information to Health Canada on a quarterly basis. They collect all the information that is required under the federal Regulations. This approach was put in place to reduce duplicative reporting in those jurisdictions that had already established MAID data collection systems. These provinces and territories are Quebec, Ontario (requests resulting in a MAID death only), Saskatchewan, Alberta, British Columbia, Northwest Territories and Nunavut.

Practitioners and pharmacists in the other provinces and territories are required to report directly to Health Canada through the Canadian MAID Data Collection Portal. These provinces and territories are Newfoundland and Labrador, Prince Edward Island, Nova Scotia, New Brunswick, Ontario (MAID requests not resulting in a MAID death), Manitoba, and Yukon. The Portal was developed and is managed in partnership with Statistics Canada and provides a secure, on-line reporting mechanism for MAID data. Health Canada provides online guidance materials for respondents and manages a MAID Report support line (phone and email) to assist respondents with questions on completing reports.

Data Collected Through Interim Reports

Prior to November 1, 2018, Health Canada collected and reported on basic data related to MAID requests by releasing a series of four interim reports available on the Health Canada website. These reports were based on data voluntarily provided to Health Canada by the provinces and territories, and data available through publicly available information in Quebec. Information in these interim reports included the total number of reported medically assisted deaths, location where MAID was provided, underlying medical condition of the person requesting MAID, type of practitioner providing MAID, gender of individual, average age of persons requesting MAID and general age range. A provincial breakdown of these details was available for Ontario, Manitoba, Saskatchewan, Alberta, and British Columbia, and in aggregate for the Atlantic provinces (Newfoundland and Labrador, Prince Edward Island, Nova Scotia and New Brunswick. Quebec’s data followed a different reporting cycle, and was not available for inclusion in the provincial breakdown within the fourth interim report.

Health Canada consulted provinces and territories during the preparation of this more comprehensive report, in order to validate and update historical numbers of cases of MAID from 2016 to 2018, as well as to validate 2019 numbers.

Methodological Notes

For all years covered in this report, the number of MAID deaths is counted in the calendar year in which the death occurred, and not in the year in which the request was received or in the year the death was reported (if they differ). For example, if a request was received in December 2018 and MAID was administered in January 2019, the reported MAID death is counted in the year 2019. Similarly, a MAID death that occurred in 2019, but was reported (as per the Regulations) in the first quarter of 2020, will be counted in the calendar year 2019. For requests not resulting in a MAID death (for example, a finding of ineligibility, withdrawal, or patient died prior to MAID), the request is counted in the calendar year in which it is received.

This report presents an updated and verified total number of MAID deaths for the calendar years 2016 to 2018. Combined with the new and more complete MAID data set collected under the authority of the Regulations, the resulting four-year chart of the number of cases of MAID provided in Canada (Chart 3.1) contributes to a better understanding of how the uptake of MAID has grown and expanded across Canada, and in each region. The expanded data collected under the Regulations also forms the basis of the detailed charts and tables for 2019 presented in this report. As with the previously published interim reports, data for the Northwest Territories and Nunavut are suppressed in order to protect confidentiality due to small numbers. Data suppression was also applied for other jurisdictions for specific indicators, as required, to protect the privacy of both patients and practitioners.

Written requests for MAID that were received prior to November 1, 2018, when the regulations came into force, were not captured, even where the outcome, including the administration of MAID, occurred after this date. This created a gap in the data of the total numbers of cases of MAID. Provinces and territories were given the opportunity to update these missing numbers for cases where MAID was provided. As a result, 2018 aggregate data is based on a combination of three data elements: previously reported data to October 31, 2018; requests prior to November 1, 2018, where MAID was provided after November 1, 2018; and data collected under the Regulations for the period November 1, 2018 to December 31, 2018. Similarly, aggregate data for MAID deaths in 2019 is based on two data elements: MAID provisions in 2019 resulting from a written request prior to November 1, 2018, and data collected under the Regulations for the period January 1, 2019 to December 31, 2019.

Finally, practitioners have the opportunity to include supplementary comments when reporting, either through their designated recipient or through the Canadian MAID Data Collection Portal. Analysis shows that this space is typically used to enter additional information to clarify previous responses, or to add information that did not fit within the standard set of data elements. Of the 5,389 reported MAID deaths in 2019, approximately 25% included additional comments by practitioners. These comments were analysed to identify common themes or patterns. Some comments that exemplify common themes have been included throughout this report (Note: names have been changed to protect the privacy of those involved).

Data Limitations

While the federal monitoring system represents the only consistent and comparable national data set on MAID, and provides the most comprehensive information available, it is not without limitations.

While all cases of MAID are captured under the current monitoring regime, it has become clear since the implementation of the federal monitoring regime in 2018 that collecting information based solely on “written requests” for MAID has resulted in data gaps in some key areas.

While the federal legislation on MAID requires a request in writing in order for MAID to be provided, there is no requirement for a written request to be submitted in order to be assessed for MAID. Since the implementation of the monitoring system in 2018, practitioners and provincial and territorial officials have indicated that many assessments for MAID are taking place with the written request only being completed once a finding of eligibility has been determined or a date for MAID has been established.

The practical effect is that a significant number of cases where the person has made a verbal request, has been assessed and found to be ineligible, are not being captured. The same is true in cases where a patient makes a verbal request for MAID, but later withdraws the request or dies prior to the completion of the assessment process. The use of the written request as the “trigger” for MAID reporting has also led to other inconsistencies in the data. For instance, many individuals who are interested in MAID begin the process through a verbal request to their primary care provider. This request frequently results in a referral to another practitioner who is a MAID assessor/provider or to a care coordination service. The patient’s request may not be formalized in writing until they are found eligible and complete the official, witnessed request several weeks later. This creates gaps in the reporting of the numbers of requests for MAID and challenges in understanding the duration of the MAID process between the initial request and the provision of MAID.

The legislation on MAID, and the supporting regulations for federal monitoring, stipulate that only physicians and nurse practitioners who receive a written request, or a pharmacist who dispenses medications for the purposes of MAID, are required to report. However, several jurisdictions have implemented MAID coordination systems, often staffed by nurses or other allied health providers who conduct preliminary assessments, to triage the intake of MAID requests. Again, this results in incomplete data as Health Canada is not authorized to collect information on cases of MAID from these supporting health providers. In particular, referrals are not captured by jurisdictions with care coordination services. This gap, along with the reasons outlined above, make the data related to referrals for MAID unreliable.

Reflections On The Past Four Years

Over the past four years, as the evidence base on MAID has grown, other places around the world have implemented legislative changes to permit some form of assisted dying. This includes five additional U.S. states (Colorado, the District of Columbia, Hawaii, Maine and New Jersey) and the Australian state of Victoria. New Zealand has also introduced legislation permitting assisted suicide (self-administered MAID), which will come into force pending a referendum in the fall of 2020.

Recognizing that there are a diversity of views on the topic, public opinion research has consistently demonstrated strong support for MAID over the past several years.  To support Canadians who choose MAID, practitioners and health system administrators across the country have made great efforts to provide quality of care and access. For instance, the Canadian Association of MAID Assessors and Providers (CAMAP) has provided a valuable forum for information sharing among health care professionals, health system administrators, policy makers and researchers. Since its creation in 2017, CAMAP has hosted an annual conference to discuss emerging issues related to the delivery of MAID and developed several guidance documents for health professionals to support exiting tools that may have been developed by provincial health regulators. At the provincial/territorial level, some jurisdictions have established MAID care coordination services and institution-level MAID teams to manage increasing numbers of MAID requests, balance the workload and distribution of a limited number of MAID assessors/providers and minimize disparities in MAID access (e.g., rural/urban).

With respect to monitoring, the reporting requirements set out in the Regulations have contributed to a better understanding of requests for MAID and associated outcomes. Procedures are being developed to make the data under the federal monitoring system available to qualified researchers upon request,  which will help to further inform and enrich the work on MAID in Canada. Future annual reports will also include an analysis of trends over time. Data linkages which would allow for more in-depth examinations of the social circumstances of persons requesting MAID (such as geography), are also being considered to support improved practice and policy decisions for social services and for health care systems. Health Canada will continue to work with provinces and territories to further improve and refine current data collection practices.

Source: Govt of Canada-Ministry of Health