Medical Assistance in Dying
NEW CRPNBC Limit on Medical-Assistance in Dying (MAiD)
On June 9, 2016, the CRPNBC Board of Directors made the decision to place a temporary limit on medical assistance in dying (MAiD) as follows:
At this time, Registered Psychiatric Nurses (RPNs) must not participate in, or support, medical assistance in dying (whether self-administered or administered by a medical practitioner or nurse practitioner) and all related activities. RPN must transfer care related to MAiD to a physician or nurse practitioner (NP). The limit includes but is not limited to the following activities:
- RPNs must not engage in conversations or provide information to clients or their families regarding medical assistance in dying (MAiD) except to transfer care related to MAiD to a physician or NP.
- RPNs must not direct, influence or counsel clients either to end their own lives or to seek assistance to cause their deaths.
- RPNs must not participate in any process used to evaluate or determine eligibility for MAiD, (e.g. acting as a witness or evaluating a client’s information in relation to stated criteria, receiving or transmitting information related to medical assistance in dying, or signing a request for MAiD on another person’s behalf).
- RPNs must not participate in MAiD or any related activities, including but not limited to:
- performing technical care, such as establishing intravenous (IV) access or carrying out other care in preparation for, or in support of, medical assistance in dying
- attending or assisting in the procedure
- prescribing, compounding, dispensing or administering substances or medications or aiding a person to self-administer substances or medications that causes or is intended to cause a person’s death
- Pronouncing death.
In addition to the limit, RPNs must meet other requirements, when applicable, such as the Scope of Practice for RPNs: Standards, Limits and Conditions, CRPNBC Practice Standards, Code of Ethics, the Professional Standards for Psychiatric Nursing , CRPNBC Bylaws, and all relevant legislation.
Registrants who have questions about MAiD should contact CRPNBC. Registrants may also seek independent legal advice.
CRPNBC is currently undertaking the process of developing updated Standards, Limits and Conditions (SLCs) for RPN practice related to MAiD. This includes research on best practices related to providing assistance in the provision of MAiD, stakeholder consultation, and Board approval. We anticipate the process will be complete by March 2017. Meanwhile, we have developed a new practice standard on Duty to Provide Care to guide RPNs on withdrawal of care, conscientious objection and other ethical considerations that are essential prior to introducing MAiD. We anticipate this new standard to be published by mid-December 2016.
If you have any further questions or concerns contact CRPNBC Practice Consultant either by telephone at (604) 931-5200 ext. 105 or email ([email protected])
Current RPN Role and Accountabilities for Palliative Care and End-of-Life Care
The CRPNBC limit on medical assistance in dying (MAiD) does not change RPNs’ existing roles and accountabilities when providing palliative and end-of-life care. RPNs continue to have an integral role in providing quality care for clients requiring end-of-life or palliative care, including:
- conducting assessments
- creating and implementing care plans
- providing comfort, care, and treatment to those who are dying and to their families
- collaborating, consulting with and referring to other members of the health care team
- advocating for clients.
RPNs provide end-of-life care for all patients including those who may be awaiting or intending to receive MAiD, subject to the limit listed above. Some of these activities may include pain management, providing comfort measures, and providing support with activities of daily living.
June 2016: New federal law passed to permit medical assistance in dying, as set out in law
On June 17, 2016, following significant debate in both the House of Commons and Senate, the federal government enacted An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), S.C. 2016, c. 3. This law is now in force in Canada.
The Act amends the Criminal Code to exempt certain persons from the potential liability they would otherwise face under the Criminal Code for, e.g. culpable homicide, counselling or aiding a suicide, intentionally causing a person’s death or administering a noxious thing. Specifically, in accordance with the defined exemptions only, the Act / amended Criminal Code permits certain persons under strictly defined circumstances to provide “medical assistance in dying” in accordance with those provisions. The Criminal Code, R.S.C. 1985, c. C-46 in its amended form now reflects these amendments1.
Notably, the Act only elaborates in detail on the roles of medical practitioners, nurse practitioners, and pharmacists; it provides very little specific reference to the roles of other health care professionals or persons (including RPNs) who might reasonably be expected to be part of a team delivering health care. The CRPNBC Board has maintained in place the temporary limit for RPNs on medical assistance in dying which was instituted on June 9, 2016, while CRPNBC studies the issue further.
A number of significant legal developments led up to and indeed, prompted, the enactment of the new federal Act which came into force on June 17, 2016. An overview of some of the legal history is described below.
2015 Supreme Court of Canada Decision
On February 6, 2015, in Carter v. Canada, the Supreme Court of Canada (SCC) found that the denial of physician-assisted death violated the Charter of Rights and Freedoms and the appropriate remedy was to declare certain parts of the Criminal Code void or invalid because they prohibit physician-assisted death2. The declaration of invalidity was set to come into effect 12 months following that decision. Following an application by the federal government for an extension of this deadline, the SCC issued an Order on January 15, 2016 granting a 4-month extension.
In the Carter decision, the SCC did not say this court-authorized relief from the application of the Criminal Code could or would apply to nurses, nor did it comment on what involvement nurses can or should undertake in physician-assisted dying or, more broadly, medical assistance in dying (i.e. dying assisted by a multi-disciplinary team of medical or health professionals)3. The BC Ministry of Justice, like some other provinces, took some steps to respond to this ambiguous legal situation. On June 8, 2016 the Criminal Justice Branch of the BC Ministry of Justice publicly announced new Charge Assessment Guidelines for prosecutors regarding physician-assisted death provided in accordance with the conditions set out in Carter. These Guidelines address the assessment of charges in relation to nurses and other health care professionals involved in carrying out, or providing information about, a physician-assisted death. For a summary of the Guidelines, see the Branch’s Media Statement.
To respond to the Carter decision and address the legal uncertainty which the Supreme Court of Canada’s decision created, in mid-April 2016 the federal government introduced Bill C-14. Finally, on June 17, 2016, An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying), S.C. 2016, c. 3 was enacted.
For more information about medical assistance in dying and the legislative history, see the Government of Canada website.
1For example, see respectively section 227 (Exemption [from culpable homicide] for medical assistance in dying), section 241 (Suicide), section 241.1. (Medical assistance in dying) and section 245 (Administering noxious thing) of the Criminal Code.
2The Carter decision only addressed the circumstance of physician-assisted death for a competent adult person who has consented to the termination of life and who 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 court noted that “irremediable” does not require the patient to undertake treatments that are not acceptable to the individual. Legal advice should be obtained for clarification of what this means.
3The court limited it to those applying “in accordance with the criteria set out in para. 127” of the original reasons for judgment in Carter – i.e., those who meet the circumstances described briefly above in footnote 2. Legal advice should be obtained for clarification of what this means.