Advance request for medical aid in dying

The information on this page does not replace that of legislation or the clinical judgment of a health or social services professional. If you have any questions, talk to a health or social services professional.

Just as for medical aid in dying requested in order to receive it in the short term (contemporaneous request), advance requests for medical aid in dying are subject to rules. A person may receive medical aid in dying only if all the criteria set out in the Act are met, both for contemporaneous requests and for advance requests. Furthermore, the competent professionals (physicians and specialized nurse practitioners) must comply with the various aspects of the Act that concern them.

It is also important to understand that an advance request for medical aid in dying cannot be made as part of an advance medical directive. They are two different processes. Advance medical directives allow a person to state what medical care they would accept or refuse in specific situations in the event of incapacity to consent to care. To understand more about what an advance medical directive is, go to the Advance medical directives page.

An advance request for medical aid in dying is made by a person who has been diagnosed with a serious and incurable illness leading to incapacity (for example, Alzheimer’s disease). The request must be made while the person is still capable of consenting to care, in order to receive medical aid in dying when they become incapable of doing so, if all the criteria set out in the Act are met.

An advance request allows a person to give their consent in advance to receive medical aid in dying in the future, under certain conditions, when they will no longer be able to consent to receiving aid.

A number of criteria must be met in order to make an advance request for medical aid in dying and to obtain aid.

An advance request for medical aid in dying may only be made by a person who has been diagnosed with a serious and incurable illness leading to incapacity to give consent to care (e.g., Alzheimer’s disease). A person may not make a request in case they get such a diagnosis one day.

When they make the request, the person must be of full age and be insured within the meaning of the Health Insurance Act. They must also be capable of giving consent to care, that is, be able to understand their medical situation and the information given, to decide what is best for them and to communicate their wishes clearly.

The request must be made freely, without external pressure. It must also be made in an informed manner, meaning that the person making the request knows, among other things, what medical aid in dying involves and that there are other therapeutic possibilities. The person must make the request themselves and for themselves.

It is important to understand that even an advance request for medical aid in dying made in accordance with the law will not automatically lead to the administration of the aid.

A person who is eligible to make an advance request for medical aid in dying under the law, and who wishes to do so, must:

• Talk with a health or social services professional in order to be assisted throughout the process. More specifically, they must identify a physician or specialized nurse practitioner who agrees to assist in completing the request using the form provided. The advance request form is available only from a physician or a specialized nurse practitioner.
• Designate one or two trusted people, if they wish, called “trusted third person”. Their role is to make sure the wishes the person expressed in their advance request for medical aid in dying are known and respected, if all the criteria set out in the Act are met. These trusted people must make sure that health or social services professionals are aware of the existence of the advance request for medical aid in dying and inform them when they observe certain situations. The trusted third person must be of full age and capable. It is not mandatory to designate a trusted third person in order to make an advance request for medical aid in dying.
• Describe in detail in their request clinical manifestations, such as symptoms, associated with their illness. The manifestations chosen by the person will constitute the expression of their consent to receive medical aid in dying when they have become incapable of consenting to care and provided all the criteria set out in the Act are satisfied.
• Sign the request form in the presence of:
  • a physician or a specialized nurse practitioner
  • two witnesses, unless the request is made by notarial act
  • the trusted third person(s), if any

When the advance request for medical aid in dying is made with witnesses, the person making the request does not have to disclose its content.

A witness may not be a minor or a person of full age who is incapable. Nor may they be designated as a trusted third person or act as a physician or a specialized nurse practitioner for the purpose of administering medical aid in dying to the person.

If the person who wishes to make an advance request for medical aid in dying cannot record it on the form or date and sign the form because they cannot write or are physically incapable of doing so, another person may do so, in their presence and as instructed by the person. The other person must meet the following criteria:

• be of full age and capable
• not be part of the care team responsible for the person who wishes to make the advance request

To be valid, the advance request must be recorded in a register provided for by law by a physician, a specialized nurse practitioner or a notary. Only the request in the register is valid, no copy is allowed. Before administering medical aid in dying, the physician or the specialized nurse practitioner must always check the register to make sure they have the latest version of the person’s advance request.

A person who is capable of consenting to care may withdraw or modify their request at any time. To do this, they must be assisted by a physician or a specialized nurse practitioner who will make sure they are still able to do so because they are still capable of consenting to care.

To withdraw an advance request for medical aid in dying, the person must ask a physician or a specialized nurse practitioner to complete the withdrawal form. The physician or the specialized nurse practitioner must confirm that the person is capable of consenting to care, sign the form and make sure the request is withdrawn, as soon as possible, from the register provided for by law.

To modify an advance request for medical aid in dying, the person must make a new request to a physician or specialized nurse practitioner. It will then replace the previous one as soon as it has been recorded in the register.

Only a person who meets all the following criteria, in addition to having made a request in accordance with the law, may obtain medical aid in dying following an advance request. The person must:

• have a serious and incurable illness leading to incapacity to give consent to care
• be incapable of giving consent to care due to their illness
• be of full age and be insured within the meaning of the Health Insurance Act, with certain exceptions provided for by law
• be exhibiting, on a recurring basis, the clinical manifestations related to their illness and described in their request
• be in a medical state of advanced, irreversible decline in capability
• be in a medical state that gives a competent professional (physician or specialized nurse practitioner) cause to believe, based on the information at their disposal and according to their clinical judgment, that the person is experiencing enduring and unbearable physical or psychological suffering that cannot be relieved under conditions considered tolerable

In addition, a second physician or specialized nurse practitioner must confirm compliance with these criteria.

If you have been diagnosed with a serious and incurable illness leading to incapacity to give consent to care and are considering making an advance request for medical aid in dying, the Guide for the person and their loved ones can support you in your reflections.

According to the Act respecting end‑of‑life care, the term “competent professional” refers to a physician or a specialized nurse practitioner. The competent professional must comply with certain obligations before administering medical aid in dying.

Furthermore, it is important to remember that a physician or a specialized nurse practitioner is not obliged to assist the person in making an advance request for medical aid in dying. In this case, however, they must help the person find a physician or a specialized nurse practitioner who can do so, as soon as possible. A physician or a specialized nurse practitioner is also not required to do the examination prescribed by law or administer medical aid in dying.

The physician or the specialized nurse practitioner who assists the person in making their advance request for medical aid in dying must make sure:

• that the person meets all the criteria for making the request
• that the person makes the request in a free and informed manner, meaning that the request is not being made as a result of external pressure and that the person has been given information concerning their illness, the anticipated course, the prognosis, the therapeutic possibilities and their consequences
• that the clinical manifestations described in the request are medically recognized as being clinical manifestations that can be related to the person’s illness
• that the clinical manifestations are observable by a competent professional (physician or specialized nurse practitioner) who would have to observe them before administering medical aid in dying
• that they have informed the person that their request will not automatically lead to the administration of medical aid in dying
• that they have informed the person of all the criteria set out in the Act
• that they have informed the person that they may withdraw or modify their advance request and how to do so

They must also:

• discuss with members of the care team who are in regular contact with the person making a request, if this is the case
• discuss with the close relations of the person making a request or with any other person they choose, if the person so wishes
• make sure that the person has had the opportunity to discuss their request with the people they wanted to contact

All signatories of the advance request for medical aid in dying must be in each other’s presence when they sign it.

The physician or the specialized nurse practitioner must then record the advance request in the register provided for by law so that it can be applicable when the time comes.

When the illness has progressed and the person has become incapable of consenting to care, a physician or a specialized nurse practitioner may be called upon to examine them. The examination must be done when a trusted third person, or any other person in certain circumstances provided by law, believes that the person:

• is exhibiting the clinical manifestations related to their illness that are described in their request
  or
• is experiencing enduring and unbearable physical or psychological suffering

As part of their examination, the physician or the specialized nurse practitioner must have a discussion with the trusted third person and with the members of the care team responsible for the person. They must also inform these people, in addition to the person who made the advance request for medical aid in dying, of the conclusions of their examination.

The physician or the specialized nurse practitioner must make sure that the process for administering medical aid in dying continues only when they conclude, after the examination:

• that the person is exhibiting, on a recurring basis, the clinical manifestations related to their illness that they described in their request
  and
• that their medical state gives cause to believe, based on the information at their disposal and according to their clinical judgment, that they are experiencing enduring and unbearable physical or psychological suffering that cannot be relieved under conditions considered tolerable

The physician or the specialized nurse practitioner must be of the opinion that the person meets all the criteria set out in the Act. They must also obtain the opinion of a second physician or specialized nurse practitioner confirming that the criteria set out in the Act have been met.

If the physician or the specialized nurse practitioner concludes that they cannot administer medical aid in dying, they must inform the following people of the reasons for their decision:

• the person concerned and also inform them of other services that can be offered to relieve their suffering
• any trusted third person designated in the request
• any health or social services professional who is a member of the care team responsible for the person

An advance request is not cancelled because a physician or a specialized nurse practitioner has concluded that they cannot administer medical aid in dying, unless this conclusion results from the refusal expressed by the person to receive such aid.

Health or social services professionals, such as nurses, licensed practical nurses or social workers, also have a role to play in the context of an advance request for medical aid in dying in addition to the care and services they usually provide.

More specifically, they are called upon to:

• answer questions from people who have been diagnosed with a serious and incurable illness leading to incapacity to give consent to care who wish to make an advance request for medical aid in dying
• help these people identify a physician or a specialized nurse practitioner who can assist them in making the request
• consult the register provided for by law as soon as they provide care to a person who has been diagnosed with a serious and incurable illness leading to incapacity to give consent to care and become aware of this incapacity. If there is an advance request for medical aid in dying, they must:
  • consult it and include it in the person’s record
  • inform the members of the care team responsible for the person of the existence of the advance request for medical aid in dying
  • make sure that any trusted third person identified in the advance request for medical aid in dying has been informed of the person’s incapacity to consent to care
• be the person, in certain cases, that the trusted third person will inform when they believe that the person concerned has become incapable of giving consent to care, in order to make known or remind them of the existence of the advance request for medical aid in dying
• be the person, in certain cases, that the trusted third person will inform when they believe that the person concerned by the advance request for medical aid in dying should be examined by a physician or a specialized nurse practitioner
• notify a physician or a specialized nurse practitioner upon receiving a notice from the trusted third person
• be the person, in certain cases, who will inform a physician or a specialized nurse practitioner that the person should be examined

If you are in a situation that causes you suffering, do not hesitate to consult a health or social services professional to assist you or to contact the 811 service if you don't have access to such a professional.