Before federal Medical Assistance in Dying (MAiD) legislation was drafted, there was considerable stakeholder discussion about the concept of a waiting/reflection period between the time a patient requested and received an assisted death. The law ultimately settled on a 10-day waiting period, starting the day after a patient completes a properly executed written request for MAiD.
On its website, the Government of Canada indicates that the purpose of the waiting period is to provide patients ample time to (re)consider their request and allow health practitioners to feel confident about the sustainability of the individual’s decision.
Most accepted this requirement as an important and reasonable safeguard. But there have been several unintended and negative consequences related to the 10-day waiting period for MAiD. Three years post legislation, it is time to reflect on whether the 10-day waiting period is an effective mechanism for confirming that a wish is enduring.
MAiD providers have relayed troubling experiences of finding their patients with unmanaged pain on the day of the procedure. Despite being encouraged to continue taking their medication as prescribed, some patients elect to reduce or stop their pain and/or sedating medications during the waiting period because they fear these drugs will affect their capacity to consent to MAiD. While the goal of MAiD is to be an end-of-life option that relieves suffering, for these individuals, their level of suffering actually increases during the waiting period.
The waiting period is also difficult for family members who are often a consistent presence at the bedside during a patient’s final days. Some have described the 10-day waiting period as “cruel punishment,” as they watched their loved one continue to suffer intolerably. It’s important to note that most patients who request MAiD have been contemplating the decision for weeks or months before they complete the written request – so waiting 10 days longer provides no additional assurance of the continuity of the patient’s desire for MAiD.
The legislation allows the 10-day waiting period to be waived if the patient is at imminent risk of either losing capacity or dying and if both MAiD assessors agree that the patient meets this criteria. In Ontario, the most recent statistics indicate that this waiting period is waived for 24 per cent of patients.1 It was documented to be reduced for 39 per cent of patients at a Toronto hospital. But we know that predictions around the timing of loss of capacity and death are fraught with error.
In our experience, there have been a number of patients who requested MAiD who unexpectedly lost capacity or died during the 10-day waiting period. We’ve witnessed surviving family members express feelings of anger and disappointment that their loved one’s death did not unfold as they had wished. Some of our patients who lost capacity experienced a lengthy dying process with complications like delirium, loss of independence, and an inability to communicate – the very things they had hoped to avoid by choosing MAiD.
Finally, the date of completion of the written request is the current trigger that starts the 10-day waiting period. As the written request must be signed, dated, and witnessed by two legally authorized individuals, the coordination of the process to complete the form can take several days. Finding witnesses who are both independent and trusted can be difficult. Instances have arisen where the written request was completed incorrectly (e.g. conflicting dates, missing signatures, ineligible witnesses). Redoing the written request delays the initiation of the waiting period. For a patient who is suffering intolerably, each additional day of waiting can be agonizing.
These are just some of the issues that we have encountered with the 10-day waiting period required for MAiD. Although it would require an amendment to legislation, there is a relatively simple solution that would resolve most of them: change the trigger for the initiation of the waiting period to when a patient first expresses to a health practitioner a desire, verbally or otherwise, to be assessed for eligibility for MAiD.
The assessments by two doctors or nurse practitioners and the completion of the written request could all be done in the ensuing 10 days. As with current practice and in accordance with the law, the patient continues to have the opportunity to change their mind about the procedure at any time, right up until the medications are administered.
Such an amendment would ensure the patient’s desire for MAID is enduring, while reducing the risk that they will die or lose capacity before they can have the death they chose. On the other hand, given the waiting period for MAiD in Ontario has been waived for 24 per cent of patients without any known concerns being raised, perhaps it’s time to consider whether the 10-day period should be significantly reduced or even eliminated altogether.
Thank you to Drs. Gail Hirano, Bill Wong and Maureen Taylor for their feedback and suggestions on earlier versions of this article.
[1] Office of the Chief Coroner/Ontario Forensic Pathology Service MAiD Data, October 31, 2019
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I’m sad to even have this discussion. My mother requested, with the support of our family, to pursue assisted death. Cancer, terminal, uncontrolled pain, begging for the suffering to end. We begged for assisted death. My mother asked four different doctors to help her die with dignity. After asking four different doctors, whom all agreed her prognosis was poor… weeks to live… she had to then wait 10 days, which is actually 12 days. It didn’t end there, Her wishes were not met. We then had to ask two additional doctors, not involved in her direct care to make a decision based on her capacity. I say again, two additional doctors that were not involved her care. Pardon? How are these “new” doctors to to decide and overrule the actual doctors involved with my mother’s ongoing care. My mom’s family doctor held her hand and sat in beside her and shed tears. She agreed assisted death. My mom’s oncologist held her hand and supported assisted death. Why then do we need two disconnected doctors? I’ve met them, they walked in our home, stood beside my mom. Mom, was on a very caring regiment of palliative care medications to ease her suffering. Narcotics for pain and sedatives. Even after a full capacity signing the request for assisted death, with two non bias witnesses present and signed, she was deemed not capable to decide because during the “10 day waiting period” she lost capacity to decide. Obviously!! She wasn’t capable, she was on heavy narcotics and sedatives. No more waiting period. Stop letting people suffer. Sign the form with capacity and let it happen as they wished. Their choice, not mine, not yours, not the public’s, not the governments, theirs and theirs only. Respect the dying.
I have advocated decriminalizing assisted voluntary suicide altogether — get it out of the criminal code — period!
For the reasons you have described above Dianne… and for several others which have been experienced with this flawed restrictive half-measure since its royal proclamation.
I wholeheartedly endorse your logical humane suggested remedy for the illogical 10 day wait period — as at least a small step toward improving this particular flaw — which, as you have observed, has caused unnecessary suffering (the very antithesis of the intent of the Supreme Court when they struck down the old law as violating all Canadians Charter Right).
Each of us nor our MDs or NPs must not be criminalized for choosing how (with or without medical assistance) and when we die —
Otherwise, some of us will choose much more violent means to exercise our right-to-die — which will undoubtedly be much more traumatic to not only our families and friends left behind, but also to any innocent onlookers and others such as train/bus/truck drivers, and first responders.
Thank you Dianne for helping advance to freedom-of-choice in this regard.
I think that Canada’s sick healthcare system stands to do nothing but benefit from assisted suicide. More so if the mentally ill, but otherwise health can also become candidates to euthanasia. The hippocratic oath can fly out the window, and thus, the gargantuan failure that is socialized healthcare can cut one more cost. So now we’ll have doctors in the business of ending lives, healthy lives at that when the mentally ill become part of assisted suicide. Why wait 10 days ? Instant death for anyone who wants it, no waiting period or reflection required.
Thank you for writing about this very important subject.
Given the fact that MAiD involves the active termination of a human life, the complete elimination of a requisite period of reflection would seem extremely irresponsible.
While the existence of the 10 day waiting period might be perceived in some instances as an unnecessary delay that merely prolongs suffering, there are other cases in which the waiting period might result in the person who originally requested MAiD having a change of heart. This possibility becomes an especially important consideration as Canada contemplates making MAiD available to individuals whose death is not reasonably foreseeable, including people whose suffering is not physiological but psychological in nature, and mature minors.
Many of us have been through times in our lives when we might well have opted for MAiD when our situation seemed hopeless or intolerable. I would think that in a great many of those cases people are glad, in retrospect, that MAiD was unavailable to them at that time.
Im sorry, do you want to streamline the medically assisted death process? Please lets not get trigger happy with this new power we’ve been given.
Disappointing coming from a SENIOR ethicist.
I firmly believe that a patient’s wish for a medically assisted death should be sustained over time; my argument is that a 10 day waiting period that begins with the patient making a written request does not achieve this goal and has caused unintended harms.
There is no such thing as universal ethics which apply to all of us homo sapiens… Therefore
I wonder who’s ethics are you promoting? … your own personal biases, or those of some un-named interest group? …with its own hidden agenda? I question the ethics of either of those.
The only ethics which come into play as I choose when and how I will die — are my own ethics and values — not yours, nor those of some interest group/church/lobby!
IF I were silly enough to choose you or some other medical practitioner (with the “new power we’ve been given”) to perform my MAID, you might object to performing MAID for me on the basis of your personal ethic and that’s fine — but that would be my problem for not dismissing you (unless you had led me along and then ‘switched’ on me at the last minute) as soon as I initiated my quest to you for my MAID.
And while we’re considering ethics, how ethical is it to not use your proper full name (like most people who stand behind their positions)? … recognizing that you could also ‘game’ that by using a real-sounding false name.