medical assistance in dying - The Registered Nurses Association of

Transcription

MEDICAL ASSISTANCE IN DYING
INTERIM GUIDELINES FOR THE NORTHWEST TERRITORIES
Effective June 17th, 2016
June 2016 | www.hss.gov.nt.ca
MEDICAL ASSISTANCE IN DYING—INTERIM GUIDELINES FOR THE NORTHWEST TERRITORIES
Contents
Purpose…. ..................................................................................................................................................... 3
Guiding Principles ......................................................................................................................................... 3
Medical Assistance in Dying Defined ............................................................................................................ 4
Privacy and Confidentiality ........................................................................................................................... 4
Information on Medical Assistance in Dying ................................................................................................ 4
Information Package ..................................................................................................................................... 4
Conscientious Objection ............................................................................................................................... 5
Central Coordinating Service ........................................................................................................................ 5
Communicating with Patient ........................................................................................................................ 5
Independent Practitioner.............................................................................................................................. 5
Request for Medical Assistance in Dying ...................................................................................................... 6
Eligibility Criteria ........................................................................................................................................... 7
Assessment of Patient by Practitioner .......................................................................................................... 8
Psychiatric Opinion (if applicable) ................................................................................................................ 9
Assessment of Patient by Consulting Practitioner ...................................................................................... 10
Reflection Period......................................................................................................................................... 11
Medical Assistance in Dying Medication(s) ................................................................................................ 11
Medical Assistance in Dying—Voluntary Euthanasia.................................................................................. 12
Medical Assistance in Dying—Administered by Patient (‘self-administration’) ......................................... 13
Reportable Death under the NWT’s Coroners Act ...................................................................................... 14
Review Committee ...................................................................................................................................... 14
Glossary……. ................................................................................................................................................ 15
Appendix A - Checklist ................................................................................................................................ 19
Appendix B – Central Coordinating Service Contact Information .............................................................. 23
Appendix C – Review Committee Contact Information .............................................................................. 24
Appendix D – Coroner Service Contact Information................................................................................... 25
June 17, 2016
DEPARTMENT OF HEALTH AND SOCIAL SERVICES
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Purpose
The Medical Assistance in Dying Interim Guidelines establish the rules and safeguards around the
request and provision of medical assistance in dying in the Northwest Territories. The purpose of
the Interim Guidelines is to protect patients, health care providers, and pharmacists throughout the
medical assistance in dying process.
Unless otherwise stated, existing procedures, protocols, or standards for health care providers,
health care facilities, health care programs, and medications are to be used in conjunction with the
Interim Guidelines.
For greater certainty, both Medical Practitioners and Nurse Practitioners may provide medical
assistance in dying under the Interim Guidelines.
Guiding Principles
The Medical Assistance in Dying Interim Guidelines are established under the following guiding
principles:
1. Any and all requests for medical assistance in dying must be initiated by the patient and
must be made voluntarily, without external pressure or advice.
2. A patient may change his/her mind regarding a request to access medical assistance in
dying at any time, for any reason, and must be provided with explicit opportunities to
withdraw his/her request, including immediately prior to the provision of medical
assistance in dying.
3. Health care providers and pharmacists who object to medical assistance in dying for
reasons of conscience or religion are not required to participate in medical assistance in
dying.
4. The choice of health care providers and pharmacists to participate in the medical assistance
in dying process must be respected.
5. A patient’s autonomy and dignity must be respected.
6. Health care providers and pharmacists must not impede the rights of a patient who wishes
to access medical assistance in dying, even if it conflicts with their conscience or religious
beliefs.
7. Decisions affecting a patient who is requesting or receiving medical assistance in dying
should respect the patient’s cultural, linguistic, and spiritual or religious ties / beliefs.
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Medical Assistance in Dying Defined
Medical assistance in dying means:
(a) the administering by a Practitioner of medication(s) to a patient, at their request, that
causes their death; or
(b) the prescribing or providing by a Practitioner of medication(s) to a patient, at their request,
so that they may self-administer the substance and in doing so cause their own death.
The Medical Assistance in Dying Interim Guidelines include both instances in which the Practitioner
provides the patient with the means to end his/her own life (‘self-administration’), and voluntary
euthanasia, where the Practitioner is directly involved in administering medication(s) to end the
patient’s life.
Privacy and Confidentiality
The collection, use, disclosure, management, retention, and disposal of information related to
medical assistance in dying, including a patient’s request for information, must adhere to existing
privacy legislation, standards, and policies.
Information on Medical Assistance in Dying
Social workers, psychologists, psychiatrists, therapists, medical practitioners, nurse practitioners,
and other health care professionals may provide information on the lawful provision of medical
assistance in dying. Information provided must be factual and should be limited to how medical
assistance in dying may be an option for patients who meet the eligibility criteria and how the
process for medical assistance in dying works in the NWT.
When information on the lawful provision of medical assistance in dying is provided to a
patient, health care providers must exercise extreme caution to ensure they do not
recommend, incite, or encourage medical assistance in dying.
If a patient chooses to make a request for medical assistance in dying, s/he must do so
voluntarily and free from any external pressure. Medical assistance in dying must not be
promoted or advocated under any circumstances, as this would constitute abetting or
counselling suicide, an offence under the Criminal Code.
Information Package
If a patient requests information on medical assistance in dying, a Health Care Provider must
provide an Information Package to the patient. The Health Care Provider is not required to review
the Information Package with the patient.
The Information Package includes a toll-free number for the Central Coordinating Service.
If a Health Care Provider chooses to review the Information Package with the patient, s/he must
ensure they follow the requirements under “Information on Medical Assistance in Dying” (above).
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Conscientious Objection
For greater certainty, other than providing an information package to a patient who requests
information on medical assistance in dying, no part of the Medical Assistance in Dying Interim
Guidelines compels a Practitioner to provide medical assistance in dying or a health care provider or
a Pharmacist to aid a Practitioner in providing medical assistance in dying to a patient.
A Central Coordinating Service has been established to facilitate access to a Practitioner who is
willing to provide more information, assess a patient, and/or provide medical assistance in dying.
Central Coordinating Service
A Central Coordinating Service is established for the Northwest Territories. The Central
Coordinating Service is responsible for facilitating access to Practitioners who are willing and able
to assess and, if applicable, provide medical assistance in dying.
A patient, a Practitioner, or another health care provider, located anywhere in the Northwest
Territories, may contact the Service.
Communicating with Patient
If a patient has difficulty communicating, a Practitioner must take all necessary measures to
provide a reliable means by which the patient may understand the information that is provided to
them and communicate their decision.
Independent Practitioner
The opinions of two Independent Practitioners are required to confirm the patient meets the
established eligibility criteria for medical assistance in dying.
A Practitioner is a Medical Practitioner, who is licensed under the NWT’s Medical Profession Act
or an Act under a province or another territory, or a Nurse Practitioner, who is licensed under the
NWT’s Nursing Profession Act or an Act under a province or another territory.
A Practitioner is considered ‘independent’ if s/he:
(a) is not a mentor to the other Practitioners (including the Psychiatrists, if applicable) involved
in the assessment of a patient or responsible for supervising their work;
(b) does not know or believe that they are beneficiary under the will of the patient making the
request, or a recipient, in any other way, of a financial or other material benefit resulting
from that patient’s death, other than standard compensation for their services relating to
the request; and
(c) does not know or believe they are connected to the other Practitioners (including the
Psychiatrists, if applicable) involved in the assessment of a patient or to the patient making
the request in any other way that would affect their objectivity.
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Request for Medical Assistance in Dying
A patient must complete form #NWT8911, Medical Assistance in Dying—Formal Written
Request by Patient, in order to make a request for medical assistance in dying. The patient must
not sign and date the request until after s/he is informed by a Practitioner that s/he has a grievous
and irremediable medical condition.
A Practitioner may only complete the appropriate section of form #NWT8911, Medical Assistance
in Dying—Formal Written Request by Patient on the specific request of a patient. A Practitioner
may complete the appropriate section by distance and fax, email, or mail the form to the patient to
complete.
If the patient requesting medical assistance in dying is unable to sign and date the form, another
person may do so on the patient’s behalf as long as the person:
(a) signs under the express direction of the patient,
(b) signs in the patient’s presence;
(c) is at least 18 years of age;
(d) understands the nature of the request for medical assistance in dying; and
(e) does not know or believe they are a beneficiary under the will of the patient or a recipient,
in any other way, of a financial or other material benefit resulting from the patient’s death.
The patient must sign and date the form before two independent witnesses. A witness is
considered independent if s/he:
(a) is at least 18 years of age;
(b) understands the nature of the request for medical assistance in dying;
(c) does not know or believe they are beneficiary under the will of the patient making the
from the patient’s death;
(d) is not the owner or operator of any health care facility at which the patient making the
request is being treated or any facility in which that patient resides;
(e) is not directly involved in providing health care services to the patient making the request;
and
(f) is not directly providing personal care to the patient making the request.
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Eligibility Criteria
In order to be eligible for medical assistance in dying, the patient must meet all of the following
criteria (‘eligibility criteria’):
(a) s/he is eligible—or, but for any applicable minimum period of residence or waiting period,
would be eligible—for health services funded by a government in Canada, such as a
provincial/territorial health care plan or a federal health care plan for those in the Canadian
Armed Forces;
(b) s/he is at least 18 years of age and capable of making decisions with respect to his/her
health;
(c) s/he has a grievous and irremediable medical condition;
(d) s/he has made a voluntary request for medical assistance in dying that, in particular, was
not made as a result of external pressure; and
(e) s/he gives informed consent to receive medical assistance in dying.
A patient has a grievous and irremediable medical condition only if they meet all of the
following:
(a) s/he has a serious and incurable illness, disease or disability;
(b) s/he is in an advanced state of irreversible decline in capability;
(c) the illness, disease or disability or that state of decline causes him/her enduring physical or
psychological suffering that is intolerable to them and that cannot be relieved under
conditions that they consider acceptable; and
(d) his/her natural death has become reasonably foreseeable, taking into account all of their
medical circumstances, without a prognosis necessarily having been made as to the specific
length of time that they have remaining.
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Assessment of Patient by Practitioner
The Practitioner must review form #NWT8911, Medical Assistance in Dying—Formal Written
Request by Patient, and ensure it was:
(a) signed and dated by the patient or, if applicable, by another person;
(b) signed and dated after the patient was informed by a Practitioner that the patient has a
grievous and irremediable medical condition;
(c) signed and dated before two independent witnesses who then also signed and dated the
form.
The Practitioner who informs the patient that s/he has a grievous and irremediable medical
condition can be the same Practitioner or Consulting Practitioner who performs the assessment of
the patient, so long as the Practitioner or Consulting Practitioner remain ‘independent’
(‘Independent Practitioner’, as defined by the Interim Guidelines).
After reviewing form #NWT8911, Medical Assistance in Dying—Formal Written Request by Patient,
the Practitioner must assess the patient to ensure s/he meets the established Eligibility Criteria.
The Practitioner must assess the patient in person.
The Practitioner must seek the opinion of a Psychiatrist if s/he is unable to determine whether the
patient is capable of making decisions with respect to his/her health.
The Practitioner must complete form #NWT8919, Medical Assistance in Dying—Assessment of
Patient by Practitioner, and include the form in the patient’s medical record.
The Practitioner must:
•
•
•
•
•
provide the patient with information on the feasible alternatives to medical assistance in
dying (ex. palliative care, pain management, etc.);
provide the patient with information on the risks of taking the medication(s) for medical
assistance in dying;
provide the patient with information on the probable outcome of taking the medication(s)
for medical assistance in dying;
recommend to the patient that s/he seek legal advice with respect to estate planning and
life insurance implications; and
offer to discuss, but not counsel on, the patient’s medical assistance in dying choice with the
patient and his/her family.
The Practitioner must inform the patient of his/her ability to withdraw the request for medical
assistance in dying at any time and in any manner and provide the patient with form #NWT8913,
Medical Assistance in Dying Withdrawal Option, and include the completed form in the patient’s
medical record.
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If the Practitioner determines the patient does not meet the established Eligibility Criteria, the
Practitioner or the patient may contact the Central Coordinating Service to request that a different
Practitioner assess the patient.
The Practitioner is responsible for providing copies of the following forms to the Review
Committee, regardless of whether the Practitioner determines the patient is eligible for medical
assistance in dying:
•
•
•
•
Formal Written Request by Patient (#NWT8911)
Assessment of Patient by Practitioner (#NWT8919)
Psychiatric Opinion (if applicable) (#NWT8916)
Withdrawal Option (#NWT8913)
The Practitioner must ensure another Practitioner (i.e. the ‘Consulting Practitioner’) provides a
written opinion confirming the patient meets the Eligibility Criteria.
Psychiatric Opinion (if applicable)
The Psychiatrist must be independent. A Psychiatrist is considered independent if s/he:
(a) is not a mentor to the Practitioners or other Psychiatrist (if applicable) involved in the
assessment of a patient or responsible for supervising their work;
(b) does not know or believe that they are beneficiary under the will of the patient making the
from that patient’s death, other than standard compensation for their services relating to
the request; or
(c) does not know or believe they are connected to the Practitioners or other Psychiatrist (if
applicable) involved in the assessment of a patient or to the patient making the request in
any other way that would affect their objectivity.
The Psychiatrist may assess the patient by distance (ex. videoconference, etc.).
The same Psychiatrist may provide an opinion for both the assessment of the patient by the
Practitioner and the Consulting Practitioner, as long as the Psychiatrist remains independent (as
defined by the Interim Guidelines).
Where applicable and as long as it does not affect a Consulting Practitioner’s independence (as
defined by the Interim Guidelines), a Consulting Practitioner may review the psychiatric opinion
requested by the Practitioner in order to assist in his/her assessment of the patient.
The psychiatric opinion on whether the patient is capable of making decisions with respect to their
health can include, but is not limited to, information on whether the patient is:
•
•
•
fully informed;
understands the information given;
appreciates the foreseeable consequences of the decision, and
June 17, 2016
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•
is able to communicate a decision based on that understanding.
The Psychiatrist must complete form #NWT8916, Medical Assistance in Dying—Psychiatric
Opinion, and include the form in the patient’s medical record.
Assessment of Patient by Consulting Practitioner
A Consulting Practitioner must assess the patient and ensure s/he meets the established Eligibility
Criteria.
The Consulting Practitioner may assess the patient by distance (ex. videoconference, etc.).
Where applicable and as long as it does not affect a Consulting Practitioner’s independence (as
defined by the Interim Guidelines), a Consulting Practitioner may review information related to the
Practitioner’s assessment of the patient, including form #NWT8919, Medical Assistance in
Dying—Assessment of Patient by Practitioner.
The Consulting Practitioner must complete form #NWT8918, Medical Assistance in Dying—
Assessment of Patient by Consulting Practitioner, and include the form in the patient’s medical
record.
The Consulting Practitioner must seek the opinion of a Psychiatrist if s/he is unable to determine
whether the patient is capable of making decisions with respect to his/her health.
The Consulting Practitioner must inform the patient of his/her ability to withdraw the request for
medical assistance in dying at any time and in any manner and provide the patient with form
#NWT8913, Medical Assistance in Dying Withdrawal Option, and include the completed form in
the patient’s medical record.
If the Consulting Practitioner determines the patient does not meet the established criteria, the
Consulting Practitioner or the patient may contact the Central Coordinating Service to request that
a different Consulting Practitioner assess the patient.
The Consulting Practitioner is responsible for ensuring the following forms are completed, included
in the patient’s medical record, and that copies are provided to the Review Committee, regardless of
whether the Consulting Practitioner determines the patient is eligible for medical assistance in
dying:
•
•
•
Assessment of Patient by Consulting Practitioner (#NWT8918)
Psychiatric Opinion (if applicable) (#NWT8916)
Withdrawal Option (#NWT8913)
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Reflection Period
The Reflection Period must pass before the Practitioner provides medical assistance in dying,
regardless of whether the medical assistance in dying will be provided through voluntary
euthanasia or if the patient will self-administer.
The reflection period is at least 10 clear days between the day on which the request was signed by
the patient and the day on which the medical assistance in dying is provided.
Day 1 = Patient signs Formal Written Request, form #NWT8911
Day 2-11 = Reflection period
Day 12 = Medical assistance in dying can be provided
A shorter reflection period is permitted if the Practitioner and the Consulting Practitioner are both
of the opinion that the patient’s death, or the loss of their capacity to provide informed consent, is
imminent.
If a shorter reflection period is agreed upon, the Practitioner and Consulting Practitioner must
complete form #NWT8914, Medical Assistance in Dying Reflection Period Amendment—
Practitioner, and form #NWT8915, Medical Assistance in Dying Reflection Period Amendment—
Consulting Practitioner, and include the forms in the patient’s medical record.
If applicable, the Practitioner is responsible for ensuring the following forms are completed,
included in the patient’s medical record, and that copies are provided to the Review Committee:
•
•
Medical Assistance in Dying Reflection Period Amendment—Practitioner (#NWT8914)
Medical Assistance in Dying Reflection Period Amendment—Consulting Practitioner
(#NWT8915)
Medical Assistance in Dying Medication(s)
The Medical Assistance in Dying Interim Pharmacy Protocols and Monographs for the Northwest
Territories is recognized as the NWT standard for all medical assistance in dying medications.
June 17, 2016
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Medical Assistance in Dying—Voluntary Euthanasia
Role of Practitioner
Medical assistance in dying must be provided with reasonable knowledge, care, and skill. The
Practitioner must exercise professional judgement in determining the appropriate medication
protocol to follow in order to achieve medical assistance in dying. The goals for any medication
protocol for medical assistance in dying include ensuring the patient is comfortable and ensuring
pain and anxiety are controlled.
The Practitioner must inform the Pharmacist, in writing, that the medication is intended for medical
assistance in dying before the Pharmacist dispenses the medication.
The Practitioner must ensure the patient gives express consent to receive medical assistance in
dying and have the patient complete form #NWT8912, Express Consent by Patient to Receive
Medical Assistance in Dying, and include the completed form in the patient’s medical record.
Immediately before administering the medication, the Practitioner must give the patient the
opportunity to withdraw his/her request. This opportunity must be documented in the patient’s
medical record.
If the patient withdraws his/her request and if s/he is able to do so, s/he must complete form
#NWT8913, Medical Assistance in Dying Withdrawal Option. The form must be included in the
patient’s medical record.
The Practitioner is responsible for ensuring the following forms are completed, included in the
patient’s medical record, and that copies are provided to the Review Committee:
•
•
Express Consent (#NWT8912)
Withdrawal Option (if applicable) (#NWT8913)
Role of Pharmacist
Medication(s) for medical assistance in dying should only be dispensed in a hospital.
A Pharmacist must only dispense medication(s) for medical assistance in dying to a health care
provider.
The Pharmacist must complete form #NWT8917, Medical Assistance in Dying—Dispensing of
Medication. The Pharmacists must provide a copy of the form to the Review Committee.
Role of Registered Nurse
A Registered Nurse may do anything within their scope of practice for the purpose of aiding a
Practitioner to provide medical assistance in dying to a patient.
If a Registered Nurse is aiding a Practitioner in providing medical assistance in dying to a patient, it
should be done so under the direct order of the Practitioner and documented in the patient’s
medical record.
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Medical Assistance in Dying—Administered by Patient (‘self-administration’)
Practitioners must help patients determine whether self-administration is a manageable option.
Considerations include, but are not limited to, whether the patient is too sick for selfadministration, or no longer capable of swallowing, holding down food, or absorbing oral
medication and whether others may attempt to impede the patient’s self-administration process.
The patient is responsible for determining when / if s/he is ready to proceed with medical
assistance in dying and may contact the Central Coordinating Service to access a Practitioner who
will provide the medication to the patient for self-administration and who will be present for the
self-administration.
Role of Practitioner
Medical assistance in dying must be provided with reasonable knowledge, care, and skill. The
Practitioner must exercise professional judgement in determining the appropriate medication
protocol to follow in order to achieve medical assistance in dying. The goals for any medication
protocol for medical assistance in dying include ensuring the patient is comfortable and ensuring
pain and anxiety are controlled.
The Practitioner must inform the Pharmacist, in writing, that the medication is intended for medical
assistance in dying before the Pharmacist dispenses the medication.
The Practitioner must be present when a patient self-administers the medication(s) for medical
The Practitioner must ensure the patient gives express consent to receive medical assistance in
dying and have the patient complete form #NWT8912, Express Consent by Patient to Receive
Medical Assistance in Dying, and include the completed form in the patient’s medical record.
Immediately before providing the medication, the Practitioner must give the patient the
opportunity to withdraw his/her request. This opportunity must be documented in the patient’s
medical record.
If the patient withdraws his/her request and if s/he is able to do so, s/he must complete form
NWT8913, Medical Assistance in Dying Withdrawal Option. The form must be included in the
patient’s medical record.
The Practitioner is responsible for ensuring the following forms are completed, included in the
patient’s medical record, and that copies are provided to the Review Committee:
•
•
Express Consent (#NWT8912)
Withdrawal Option (if applicable) (#NWT8913)
Role of Pharmacist
Medication(s) for medical assistance in dying should only be dispensed in a hospital.
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A Pharmacist must only dispense medication(s) for medical assistance in dying to a health care
provider.
The Pharmacist must complete form #NWT8917, Medical Assistance in Dying—Dispensing of
Medication. The Pharmacists must provide a copy of the form to the Review Committee.
Role of Registered Nurse
A Registered Nurse may do anything within their scope of practice for the purpose of aiding a
Practitioner to provide a patient with medical assistance in dying.
If a Registered Nurse is aiding a Practitioner in providing medical assistance in dying to a patient, it
should be done so under the direct order of the Practitioner and documented in the patient’s
medical record.
Reportable Death under the NWT’s Coroners Act
Medical assistance in dying is currently a reportable death under the NWT’s Coroners Act.
Coroner Service contact information is included in Appendix D.
The Coroner, not the Practitioner, is responsible for completing the Medical Certificate of Death
portion of the Death Registration Statement.
Review Committee
A Review Committee is established for the Northwest Territories.
The Review Committee is responsible for:
•
•
Maintaining medical assistance in dying records
Reviewing, auditing and investigating medical assistance in dying cases.
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Glossary
Central Coordinating Service
Service that is responsible for facilitating access to Practitioners who are willing to provide
information on, assess and, if applicable, provide medical assistance in dying.
Where medical assistance in dying is administered by the patient (i.e. self-administered),
the Central Coordinating Service will also facilitate a patient’s access to a Practitioner who
must be present when the patient is ready to proceed with the medical assistance in dying
self-administration process.
Contact information for the Central Coordinating Service can be found in Appendix B.
Eligibility Criteria
Criteria a patient must meet in order to be eligible for medical assistance in dying. The
eligibility criteria includes ALL of the following:
(a) s/he is eligible—or, but for any applicable minimum period of residence or
waiting period, would be eligible—for health services funded by a government
in Canada, such as a provincial/territorial health care plan or a federal health
care plan for those in the Canadian Armed Forces;
(b) s/he is at least 18 years of age and capable of making decisions with respect to
his/her health;
(c) s/he has a ‘grievous and irremediable medical condition’ (as defined in the
Interim Guidelines);
(d) s/he has made a voluntary request for medical assistance in dying that, in
particular, was not made as a result of external pressure; and
(e) s/he gives informed consent to receive medical assistance in dying.
Forms (Medical Assistance in Dying)
•
•
•
•
•
Assessment of Patient by Practitioner, form #NWT8919—must be completed when a
Practitioner assesses a patient’s eligibility for medical assistance in dying.
Assessment of Patient by Consulting Practitioner, form #NWT8918—must be completed
when a Consulting Practitioner assesses a patient to confirm they meet the eligibility
criteria.
Dispensing of Medication, form #NWT8917—must be completed by a Pharmacist who
dispenses medication(s) for medical assistance in dying.
Express Consent by Patient, form #NWT8912—must be completed by a patient prior to the
Practitioner providing medical assistance in dying (i.e. prior to the administration or
providing of medication(s) for medical assistance in dying).
Formal Written Request by Patient, form #NWT8911—must be completed by a patient
prior to the patient being assessed by a Practitioner for medical assistance in dying.
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•
•
•
•
Psychiatric Opinion, form #NWT8916—must be completed by a Psychiatrist if their
opinion is requested by a Practitioner and/or Consulting Practitioner to assess whether the
patient is capable of making decisions about his/her health.
Reflection Period Amendment—Practitioner, form #NWT8914—must be completed by a
Practitioner if medical assistance in dying will be provided in a shorter period of time than
the established reflection period.
Reflection Period Amendment—Consulting Practitioner, form #NWT8915—must be
completed by a Consulting Practitioner if medical assistance in dying will be provided in a
shorter period of time than the established reflection period.
Withdrawal Option, form #NWT8913—must be completed by a patient during his/her
assessment by a Practitioner and his/her assessment by a Consulting Practitioner.
Grievous and Irremediable Medical Condition
A patient has a grievous and irremediable medical condition only if they meet all of the
following:
(f) s/he has a serious and incurable illness, disease or disability;
(g) s/he is in an advanced state of irreversible decline in capability;
(h) the illness, disease or disability or that state of decline causes him/her enduring
physical or psychological suffering that is intolerable to them and that cannot be
relieved under conditions that they consider acceptable; and
(i) his/her natural death has become reasonably foreseeable, taking into account all
of their medical circumstances, without a prognosis necessarily having been
made as to the specific length of time that they have remaining.
Health care provider
A Medical Practitioner, Nurse Practitioner, or Registered Nurse who is considered
‘independent’, as defined by the Interim Guidelines.
(Independent) Consulting Practitioner
A Medical Practitioner, who is licensed under the NWT’s Medical Profession Act or an Act
under a province or another territory, or a Nurse Practitioner, who is licensed under the
NWT’s Nursing Profession Act or an Act under a province or another territory, who is
responsible for assessing the patient and confirming they meet the eligibility criteria for
medical assistance in dying.
A Consulting Practitioner is considered independent if s/he meets ALL of the following:
(a) is not a mentor to the other Practitioners (including the Psychiatrists, if
applicable) or responsible for supervising their work;
(b) does not know or believe they are beneficiary under the will of the patient
making the request, or a recipient, in any other way, of a financial or other
material benefit resulting from that patient’s death, other than standard
compensation for their services to the request; and
June 17, 2016
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(c) does not know or believe they are connected to the other Practitioners involved
in the assessment of the same patient (including the Psychiatrists, if applicable),
or to the patient making the request in any other way that would affect their
objectivity.
(Independent) Practitioner
A Medical Practitioner, who is licensed under the NWT’s Medical Profession Act or an Act
under a province or another territory, or a Nurse Practitioner, who is licensed under the
NWT’s Nursing Profession Act or an Act under a province or another territory, who is
responsible for assessing the patient and ensuring they meet the eligibility criteria for
A Practitioner is considered independent if s/he meets ALL of the following:
(a) is not a mentor to the other Practitioners (including the Psychiatrists, if
applicable) or responsible for supervising their work;
(c) does not know or believe they are connected to the Practitioners involved in the
assessment of the same patient (including the Psychiatrists, if applicable) or to
the patient making the request in any other way that would affect their
objectivity.
(Independent) Psychiatrist
A Psychiatrist, who is a Medical Practitioner licensed under the NWT’s Medical Profession
Act or an Act under a province or another territory, who is responsible for assessing the
patient and providing an opinion on whether patient is capable of making decisions with
respect to his/her health upon the request of the Practitioner and/or the Consulting
Practitioner.
A Psychiatrist is considered independent if s/he meets ALL of the following:
(a) is not a mentor to the Practitioners or other Psychiatrist (if applicable) or
responsible for supervising their work;
(c) does not know or believe they are connected to the Practitioners involved in the
assessment of the same patient or the other Psychiatrist (if applicable) or to the
patient making the request in any other way that would affect their objectivity.
Registered Nurse
A Registered Nurse, who is licensed under the NWT’s Nursing Profession Act.
June 17, 2016
Page 17 of 25
Information Package
Information that must be provided by a health care provider when a patient requests
information on medical assistance in dying.
Medical Assistance in Dying
Medical assistance in dying means:
(a) the administering by a Practitioner of medication(s) to a patient, at their
request, that causes their death; or
(b) the prescribing or providing by a Practitioner of medication(s) to a patient, at
their request, so that they may self-administer the substance and in doing so
cause their own death.
Reflection Period
The requirement where at least 10 clear days have passed between the day on which the
patient signed and dated form #NWT8911, Medical Assistance in Dying—Formal Written
Request, and the day on which the medical assistance in dying is provided:
Day 1 = Patient signs Formal Written Request, form #NWT8911
Day 2-11 = Reflection period
Day 12 = Medical assistance in dying can be provided
Note: Medical assistance in dying can be provided in a shorter period of time if the
Practitioner and the Consulting Practitioner are both of the opinion that the patient’s
death, or the loss of their capacity to provide informed consent, is imminent.
If a shorter period of time is agreed upon, the Practitioner and the Consulting
Practitioner must complete form #NWT8914, Medical Assistance in Dying
Reflection Period Amendment—Practitioner, and form #NWT8915, Medical
Assistance in Dying Reflection Period Amendment—Consulting Practitioner.
Review Committee
Person(s) responsible for maintaining medical assistance in dying records and for
reviewing, auditing, and investigating medical assistance in dying cases.
June 17, 2016
Page 18 of 25
Appendix A - Checklist
Practitioners may use the following checklist to ensure all the safeguards are being met and that
medical assistance in dying is being provided in accordance with the Medical Assistance in Dying
Interim Guidelines for the Northwest Territories.
STEP ONE: ASSESSMENT OF PATIENT BY PRACTITIONER
___
___
___
___
___
___
___
___
Form #NWT8911, Medical Assistance in Dying—Formal Written Request by Patient, is
completed, and was signed and dated after the patient was informed by a Practitioner that
the patient has a grievous and irremediable medical condition.
Assessment is performed by an Independent Practitioner.
Form #NWT8911, Medical Assistance in Dying—Formal Written Request by Patient, is
included in the patient’s medical record and a copy is provided to the Review Committee.
The patient is assessed in person to ensure they meet the eligibility criteria. The
assessment is documented on form #NWT8919, Medical Assistance in Dying—Assessment of
Patient by Practitioner.
Form #NWT8919, Medical Assistance in Dying—Assessment of Patient by Practitioner, is
included in the patient’s medical record and a copy is provided to the Review Committee.
The patient is informed of their ability to withdraw from the medical assistance in dying
process at any time and in any manner and provided with form #NWT8913, Medical
Assistance in Dying—Withdrawal Option.
Form #NWT8913, Medical Assistance in Dying—Withdrawal Option, is included in the
patient’s medical record and a copy is provided to the Review Committee.
A second assessment by a Consulting Practitioner is requested to confirm the patient meets
the eligibility criteria.
PSYCHIATRIC OPINION (WHERE APPLICABLE) FOR ASSESSMENT BY PRACTITIONER
___
Opinion is provided by an Independent Psychiatrist
___
Form #NWT8916, Medical Assistance in Dying—Psychiatric Opinion is included in the
___
Psychiatrist assesses the patient, either in person or by distance, and provides an opinion
on whether the patient is capable of making decisions with respect to their health. The
opinion is documented in form #NWT8916, Medical Assistance in Dying—Psychiatric
Opinion.
June 17, 2016
Page 19 of 25
STEP TWO: ASSESSMENT OF PATIENT BY CONSULTING PRACTITIONER
___
Assessment is performed by an Independent Consulting Practitioner.
___
The patient is assessed, either in person or by distance, to confirm they meet the eligibility
criteria. The assessment is documented on form #NWT8918, Medical Assistance in Dying—
Assessment of Patient by Consulting Practitioner.
___
Form NWT8918, Medical Assistance in Dying—Assessment of Patient by Consulting
Practitioner, is included in the patient’s medical record and a copy is provided to the Review
Committee.
___
___
___
The patient is informed of their ability to withdraw from the medical assistance in dying
process at any time and in any manner and provided with form #NWT8913, Medical
Assistance in Dying—Withdrawal Option.
Form NWT8913, Medical Assistance in Dying—Withdrawal Option, is included in the
The Consulting Practitioner confirms with the Practitioner that the patient meets the
eligibility criteria for medical assistance in dying.
PSYCHIATRIC OPINION (WHERE APPLICABLE) FOR ASSESSMENT BY CONSULTING
PRACTITIONER
___
___
___
Opinion is provided by an Independent Psychiatrist.
Psychiatrist assesses the patient, either in person or by distance, and provides an opinion
on whether the patient is capable of making decisions with respect to their health. The
opinion is documented in form #NWT8916, Medical Assistance in Dying—Psychiatric
Opinion.
Form #NWT8916, Medical Assistance in Dying—Psychiatric Opinion, is included in the
STEP THREE: REFLECTION PERIOD
___
At least 10 clear days have passed between the day on which form #NWT8911, Medical
Assistance in Dying—Formal Written Request by Patient, was completed and the day on
which medical assistance in dying is provided.
--OR--
___
Fewer than 10 clear days have passed between the day on which form #NWT8911, Medical
Assistance in Dying—Formal Written Request by Patient, was completed and the day on
which medical assistance in dying is provided, and:
June 17, 2016
Page 20 of 25
(a) Form #NWT8914, Medical Assistance in Dying Reflection Period Amendment—
Practitioner, is completed, included in the patient’s medical record, and a copy is
provided to the Review Committee; and
(b) Form #NWT8915, Medical Assistance in Dying Reflection Period Amendment—
Consulting Practitioner, is completed, included in the patient’s medical record,
and a copy is provided to the Review Committee.
STEP FOUR: MEDICAL ASSISTANCE IN DYING
___
The Practitioner ensures all the following safeguards are met:
(a) Patient meets all of the eligibility criteria:
i. s/he is eligible—or, but for any applicable minimum period of residence or
waiting period, would be eligible—for health services funded by a
government in Canada, such as a provincial/territorial health care plan or a
federal health care plan for those in the Canadian Armed Forces;
ii. s/he is at least 18 years of age and capable of making decisions with respect
to their health;
iii. s/he has a grievous and irremediable medical condition;
iv. s/he has made a voluntary request for medical assistance in dying that, in
particular was not made as a result of external pressure; and
v. s/he gives informed consent to receive medical assistance in dying.
(b) The patient’s request for medical assistance in dying was:
i. made in writing and signed and dated by the patient or, if applicable, by
another person;
ii. signed and dated after the patient was informed by a Practitioner that s/he
has a grievous and irremediable medical condition; and
iii. signed and dated before two independent witnesses who then also signed
and dated.
(c) The patient has been informed that they may, at any time and in any manner,
withdraw their request;
(d) Another Practitioner (i.e. the Consulting Practitioner) has provided a written
opinion confirming that the patient meets all of the eligibility criteria;
(e) Practitioner and Consulting Practitioner are independent;
(f) At least 10 clear days between the day on which the request was signed by the
patient and the day on which the medical assistance in dying is provided or—if
they and the Consulting Practitioner are both of the opinion that the patient’s
death, or the loss of their capacity to provide informed consent, is imminent—
any shorter period that the Practitioner considers appropriate in the
circumstances; and
June 17, 2016
Page 21 of 25
___
___
___
___
(g) If the patient has difficulty communicating, the Practitioner has taken all
necessary measures to provide a reliable means by which the patient may
understand the information that is provided to them and communicate their
decision.
The Practitioner informs the Pharmacist, in writing, that the medication is intended for
medical assistance in dying before the Pharmacist dispenses the medication.
The patient completes form #NWT8912, Express Consent by Patient to Receive Medical
Assistance in Dying. The form is included in the patient’s medical record and a copy is
provided to the Review Committee.
The patient is given the opportunity to withdraw his/her request for medical assistance in
dying by the Practitioner immediately before the Practitioner administers the medication
(‘voluntary euthanasia’) or provides the medication to the patient (‘self-administration’).
This opportunity is documented in the patient’s medical record.
The Practitioner reports the death to the Coroner.
June 17, 2016
Page 22 of 25
Appendix B – Central Coordinating Service Contact Information
Monday to Friday: 8:30am – 5:00pm
Toll Free: 1 (855) 846-9601
Direct: 1 (867) 767-9050 ext. 49008
June 17, 2016
Page 23 of 25
Appendix C – Review Committee Contact Information
Director, Territorial Health Services
Department of Health and Social Services
Government of the Northwest Territories
Phone: 1(867) 767-9062 ext. 49190
June 17, 2016
Page 24 of 25
Appendix D – Coroner Service Contact Information
Coroner Service
Email: [email protected]
Phone: 1-867-767-9251
Toll-free (24 hours): 1-866-443-4443
Fax: 1-867-873-0426
June 17, 2016
Page 25 of 25
MEDICAL ASSISTANCE IN DYING –
FORMAL WRITTEN REQUEST BY PATIENT
I,
, have
(Name of Practitioner, please print)
informed
on
(Patient Name, please print)
(Date - D/M/Y)
(Name of Medical Condition)
Signature of Practitioner
Je soussigné(e),
(Nom du practicien en caractères d’imprimerie)
déclare avoir informé
that he or she has a grievous and
irremediable medical condition1
AIDE MÉDICALE À MOURIR –
DEMANDE ÉCRITE OFFICIELLE DU PATIENT
le
(Nom du patient en caractères d’imprimerie)
(Date - J/M/A)
. de santé grave et irrémédiable1 :
Date - D/M/Y
Phone Number of Practitioner
qu’il est affecté d’un problème
Signature du praticien
,
(Nom du problème de santé)
.
Date - J/M/A
Numéro de téléphone du praticien
Patient Information / Renseignements sur le patient
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Numéro d’assurance-maladie
Telephone Number
Numéro de téléphone
Address
Adresse
Illness, Disease, or Disability Leading to Request
Maladie, affection ou handicap à l’origine de la demande
I,
, am
making this request for medical assistance in dying. I am making
this request voluntarily, and not as a result of external pressure.
I am
years of age and capable of making decisions
with respect to my health.
I am a resident of Canada, and I am eligible for health care
coverage under a provincial/territorial plan. My health care
number is:
1
A person has a grievous and irremediable medical condition if:
(a) They have a serious and incurable illness, disease or disability;
(b) They are in an advanced state of irreversible decline in capability;
(c) That illness, disease or disability or that state of decline causes them
enduring physical or psychological suffering that is intolerable to them and
that cannot be relieved under conditions that they consider acceptable;
and
(d) Their natural death has become reasonably foreseeable, taking into
account all of their medical circumstances, without a prognosis necessarily
having been made as to the specific length of time that they have
remaining.
See reverse to complete the Formal Written Request.
Forgery is an offence under the Criminal Code.
Je soussigné(e),
soumets cette demande d’aide médicale à mourir. Je fais cette
demande de manière volontaire et sans pression extérieure.
J’ai
ans et je suis capable de prendre des décisions en
ce qui concerne ma santé.
Je suis résident canadien et je suis admissible à l’assurancemaladie d’une province ou d’un territoire. Mon numéro
d’assurance-maladie est le :
Une personne est affectée d’un problème de santé grave et irrémédiable lorsque,
à la fois :
a) elle est atteinte d’une maladie, d’une affection ou d’un handicap graves et
incurables;
b) sa situation médicale se caractérise par un déclin avancé et irréversible de
ses capacités;
c) sa maladie, son affection, son handicap ou le déclin avancé et irréversible
de ses capacités lui cause des souffrances physiques ou psychologiques
persistantes qui lui sont intolérables et qui ne peuvent être apaisées dans
des conditions qu’elle juge acceptables;
d) sa mort naturelle est devenue raisonnablement prévisible compte tenu de
l’ensemble de sa situation médicale, sans pour autant qu’un pronostic ait
été établi quant à son espérance de vie.
1
Pour remplir la demande écrite officielle, voir le verso.
La falsification de documents constitue une infraction au Code criminel.
If you would like this information in another official language, contact us at 1-855-846-9601.
Si vous voulez ces informations dans une autre langue officielle, téléphonez nous au 1-855-846-9601.
NWT8911/0616
,
Page 1 of 4 / 1 de 4
Why are you making the request for medical assistance in
dying? (Additional room is provided on the back.)
Pourquoi demandez-vous l’aide médicale à mourir? (Si vous
avez besoin de plus d’espace, utilisez le verso de la feuille.)
This request is my informed consent to receive medical
Cette demande fait état de ma décision éclairée de recevoir l’aide
assistance in dying. I understand that I can withdraw this request médicale à mourir. Je comprends que je peux retirer ma demande
at any time and in any manner.
en tout temps et par tout moyen.
Patient Signature
** Witness #1 to Patient Signature
** Witness #2 to Patient Signature
* Signature of Person Signing on Behalf of Patient
if Patient is Unable to Sign
Date - D/M/Y
** Premier témoin de la signature du patient
Date - D/M/Y
** Deuxième témoin de la signature du patient
Date - D/M/Y
* Signature de la personne signant au nom du patient
(si celui-ci en est incapable)
* Signature of Person Signing on Behalf of Patient if Patient
is Unable to Sign (i.e. not a witness)
I,
(Name of Person Signing on Behalf of Patient, please print)
(Name of Patient, please print)
, understand
is making
a formal request for medical assistance in dying. As the person
signing on behalf of the patient, I confirm that:
• I am at least 18 years of age;
• I understand the nature of the request for medical assistance
in dying;
• I am signing and dating the request on the patient’s behalf,
under their express direction and in their presence;
• I do not know or believe I am a beneficiary under the will of
the patient or a recipient, in any other way, of a financial or
other material benefit resulting from the patient’s death.
NWT8911/0616
Date - D/M/Y
Phone Number of Person Signing on Behalf of Patient
Signature du patient
Date - D/M/Y
Date - J/M/A
Date - J/M/A
Date - J/M/A
Date - J/M/A
*Signature de la personne signant au nom du patient
incapable de signer (si celui-ci en est incapable –
c.-à-d. une personne autre qu’un témoin)
Je soussigné(e),
comprends que
(Nom de la personne signant au nom du patient
en caractères d’imprimerie)
,
fait une demande officielle d’aide médicale à mourir. En tant que
personne signant au nom du patient, je confirme que :
• je suis âgé d’au moins dix-huit ans;
• je comprends la nature de la demande d’aide médicale à
mourir;
• je signe et date la demande en la présence du patient et en
son nom;
• je ne sais pas si je figure ou ne crois pas que je figure
au testament du patient qui fait la demande à titre de
bénéficiaire, ou je ne sais pas si je retirerai ou ne crois
pas que je retirerai des avantages financiers ou matériels
découlant du décès de ce patient.
Date - J/M/A
Numéro de téléphone de la personne signant au nom du patient
** Independent Witness #1
I,
that
** Premier témoin indépendant
(Name of Independent Witness, please print)
, understand
has made
a formal request for medical assistance in dying. As a witness to
that request, I confirm that:
in dying;
the patient making the request, or a recipient, in any other
way, of a financial or other material benefit resulting from
the patient’s death;
• I am not an owner or operator of any health care facility at
which the patient making the request is being treated or any
facility in which the patient resides;
• I am not directly involved in providing health care services to
the patient making the request; and
• I do not directly provide personal care to the patient making
the request.
Witness Signature
Date - D/M/Y
Phone Number of Independent Witness #1
** Independent Witness #2
I,
that
, understand
has made
NWT8911/0616
Witness Signature
comprends que
(Nom du témoin indépendant en caractères d’imprimerie)
,
a fait une demande officielle d’aide médicale à mourir. En tant
que témoin de cette demande, je confirme que :
mourir;
• je ne suis pas ou ne crois pas être bénéficiaire de la
succession testamentaire de la personne qui fait la demande
et je ne recevrai pas ou ne crois pas que je recevrai
autrement un avantage matériel, notamment pécuniaire, de
la mort de celle-ci;
• je ne suis pas propriétaire ou exploitant de l’établissement
de soins de santé où la personne qui fait la demande reçoit
des soins ou de l’établissement où celle-ci réside;
• je ne participe pas directement à la prestation de services de
soins de santé à la personne qui fait la demande;
• je ne fournis pas directement des soins personnels à la
personne qui fait la demande.
Signature du témoin
Date - J/M/A
Numéro de téléphone du 1er témoin indépendant
** Deuxième témoin indépendant
in dying;
• I am not directly involved in providing health care services to
the patient making the request; and
the request.
Je soussigné(e),
Phone Number of Independent Witness #2
Date - D/M/Y
Je soussigné(e),
comprends que
,
mourir;
• je ne suis pas propriétaire ou exploitant de l’établissement
des soins ou de l’établissement où celle-ci réside;
Date - J/M/A
Numéro de téléphone du 2e témoin indépendant
Additional space
NWT8911/0616
Espace supplémentaire
ASSESSMENT OF PATIENT BY
PRACTITIONER
ÉVALUATION DU PATIENT PAR LE
PRATICIEN
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
Assessment of patient, including the practitioner’s opinion
and specific information on whether the patient suffers from a
grievous and irremediable medical condition:1
Évaluation du patient, comprenant l’avis du praticien et des
renseignements spécifiques indiquant si le patient souffre d’un
problème de santé grave et incurable :1
(See reverse for additional space.)
(Voir au verso si vous avez besoin de plus d’espace.)
I have:
provided the patient with information on the feasible
alternatives to medical assistance in dying (ex. palliative care,
pain management, etc.),
provided the patient with information on the risks of taking
the medication(s) for medical assistance in dying,
provided the patient with information on the probable
outcome of taking medication for medical assistance in dying,
recommended to the patient that he or she seek legal
advice with respect to estate planning and life insurance
implications, and
offered to discuss the patient’s medical assistance in dying
choice with the patient and his or her family.
“Grievous and irremediable medical condition” – A person has a
grievous and irremediable medical condition if:
(c) That illness, disease or disability or that state of decline causes
them enduring physical or psychological suffering that is
intolerable to them and that cannot be relieved under conditions
that they consider acceptable; and
(d) Their natural death has become reasonably foreseeable, taking
into account all of their medical circumstances, without a
prognosis necessarily having been made as to the specific length of
time that they have remaining.
1
See reverse to complete the Assessment Form.
J’ai :
fourni au patient des renseignements sur les autres
possibilités en dehors de l’aide médicale à mourir (soins
palliatifs, gestion de la douleur, etc.),
prévenu le patient des risques associés à la prise des
médicaments dans le cadre de l’aide médicale à mourir,
prévenu le patient de l’issue probable s’il prend de tels
médicaments;
recommandé au patient de se renseigner sur le plan
juridique concernant les répercussions de sa décision en
matière de planification successorale et d’assurance-vie;
proposé de discuter avec le patient et sa famille de son choix
concernant l’aide médicale à mourir.
« Problème de santé grave et incurable » – Une personne est affectée
d’un problème de santé grave et irrémédiable lorsque, à la fois :
a) elle est atteinte d’une maladie, d’une affection ou d’un handicap
graves et incurables;
b) sa situation médicale se caractérise par un déclin avancé et
irréversible de ses capacités;
c) sa maladie, son affection, son handicap ou le déclin avancé et
irréversible de ses capacités lui cause des souffrances physiques
ou psychologiques persistantes qui lui sont intolérables et qui ne
peuvent être apaisées dans des conditions qu’elle juge acceptables;
d) sa mort naturelle est devenue raisonnablement prévisible compte
tenu de l’ensemble de sa situation médicale, sans pour autant
qu’un pronostic ait été établi quant à son espérance de vie.
1
Veuillez continuer de remplir le formulaire au verso.
NWT8919/0616
I have provided the patient with a copy of the Withdrawal
Option, form NWT8913, and informed the patient that they
may, at any time and in any manner, withdraw their request
for medical assistance in dying.
The patient meets the following eligibility criteria for medical
They are eligible – or, but for any applicable minimum
period of residence or waiting period, would be eligible –
for health services funded by a government in Canada;
They are at least 18 years of age and capable of making
decisions with respect to their health;
They have a grievous and irremediable medical condition;
They have made a voluntary request for medical assistance
in dying that, in particular, was not made as a result of
external pressure (i.e. completed the Medical Assistance in
Dying – Formal Written Request form NWT8911); and
They give informed consent to receive medical assistance in
dying.
I understand that in order to provide medical assistance in
dying to the patient, a Consulting Practitioner must assess
the patient to confirm the patient meets all of the eligibility
criteria.
J’ai fourni au patient une copie du Formulaire NWT8913 –
Possibilité de rétractation, et je l’ai informé qu’il pouvait
à tout moment et de quelque façon, annuler sa demande
d’aide médicale à mourir.
Le patient doit répondre aux critères suivants pour demander
l’aide médicale à mourir :
Il est admissible ou le sera (pour des raisons de délai
d’attente ou de durée de résidence à respecter) aux services
de santé financés par le gouvernement du Canada;
Il est âgé d’au moins 18 ans et est en mesure de prendre des
décisions quant à sa santé;
Il souffre d’un problème de santé grave et incurable;
Il a délibérément demandé l’aide médicale à mourir,
sans pressions extérieures (et il a notamment rempli le
formulaire NWT8911 intitulé Aide médicale à mourir –
Demande écrite officielle du patient);
Il a donné son consentement éclairé de recevoir l’aide
médicale à mourir.
J’atteste avoir compris qu’avant de fournir une aide médicale
à mourir au patient, il faut qu’un praticien consultant évalue le
patient pour confirmer qu’il répond à l’ensemble des critères.
Practitioner Information
Renseignements sur le praticien
Name
Nom
Signature / Signature
Name and Address of Facility
Nom et adresse du cabinet
Date - D/M/Y - J/M/A
Phone Number of Practitioner / Numéro de téléphone du praticien
Assessment Notes (continued) / Conclusions de l’évaluation (suite) :
NWT8919/0616
WITHDRAWAL OPTION
POSSIBILITÉ DE RÉTRACTATION
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
I,
, Je soussigné(e),
have been advised by
I,
am choosing to withdraw from the medical assistance in
dying process.
déclare avoir été prévenu par
and am aware of my ability to withdraw from the medical assistance
in dying process at any time and for any reason. I understand that
withdrawing from the medical assistance in dying process does
not preclude me from re-requesting medical assistance in dying
at a later date.
,
am choosing to continue with the medical assistance in
dying process.
Patient Signature
Je soussigné(e),
déclare avoir décidé de me retirer du processus de l’aide
,
OU
,
Je soussigné(e),
déclare avoir décidé de continuer le processus de l’aide
Date - D/M/Y
Date - D/M/Y
See reverse to complete the Medical Assistance in Dying –
Withdrawal Option.
,
(Nom du praticien en caractères d’imprimerie)
et être conscient de ma possibilité de me rétracter quant à l’aide
médicale à mourir, à tout moment et pour quelque raison que
ce soit. Je comprends que le fait de retirer ma demande d’aide
médicale à mourir ne m’enlève pas le droit de déposer une nouvelle
demande ultérieurement.
OR
I,
,
Date - J/M/A
Date - J/M/A
NWT8913/0616
I,
, understand
is making
in dying;
NWT8913/0616
Date - D/M/Y
(si celui-ci en est incapable – c.-à-d. une personne autre
qu’un témoin)
Je soussigné(e),
comprends que
,
personne signant au nom du patient, je confirme que :
mourir;
son nom;
Date - J/M/A
PSYCHIATRIC OPINION
EXPERTISE PSYCHIATRIQUE
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
Psychiatric opinion was requested by:
Assessment of patient, including the Psychiatrist’s opinion
and specific information on whether the patient is capable of
making decisions with respect to his or her health:
Assessment was performed:
in person or by distance
See reverse to complete the Psychiatric Opinion Form.
.
Une expertise psychiatrique a été demandée par :
Évaluation du patient, comprenant l’expertise psychiatrique et
des renseignements spécifiques indiquant si le patient est en
mesure de prendre des décisions concernant sa santé :
(Continuez au verso si vous avez besoin de plus d’espace.)
L’évaluation a été effectuée :
en personne ou Remplir le formulaire au verso.
.
à distance
NWT8916/0616
I,
(Psychiatrist Name, please print)
, Je soussigné(e),
state and confirm that I:
déclare et confirme que :
am not a mentor to, or responsible for supervising the work of,
je ne suis ni un mentor ni un superviseur de,
(Patient’s Name, please print)
do not know or believe that I am connected to
do not know or believe that I am a beneficiary under the will of
or a recipient, in any other way, of a financial or other material
benefit resulting from the death of
; ; and
or to
in any way that affects my objectivity.
Psychiatrist Information / Renseignements sur le psychiatre
Name
Nom
(Signature of Psychiatrist, Signature du psychiatre)
j’ignore et ne crois pas avoir un lien familial avec
;
;
j’ignore et ne crois pas être un bénéficiaire du testament du
patient, ou de tout autre don matériel ou financier à la suite du
décès de
; ,
(Nom du psychiatre en caractères d’imprimerie)
ou
qui influerait le moindrement sur mon objectivité.
;
;
;
Phone Number of Psychiatrist / Numéro de téléphone du psychiatre
Psychiatrist Assessment Notes (continued) / Conclusions de l’expertise psychiatrique (suite) :
NWT8916/0616
ASSESSMENT OF PATIENT BY
CONSULTING PRACTITIONER
ÉVALUATION DU PATIENT PAR LE
PRATICIEN CONSULTANT
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
Assessment of patient, including the practitioner’s opinion and Évaluation du patient, comprenant l’avis du praticien et des
specific information on whether the patient meets the eligibility renseignements spécifiques indiquant si le patient répond aux
criteria and whether the patient suffers from a grievous and
critères et souffre d’un problème de santé grave et incurable :1
1
irremediable medical condition:
Assessment was performed:
in person or (Voir au verso si vous avez besoin de plus d’espace.)
by distance
I have provided the patient with a copy of the Withdrawal
Option, form NWT8913, and informed the patient that they
may, at any time and in any manner, withdraw their request.
“Grievous and irremediable medical condition” – A person has a
grievous and irremediable medical condition if:
(c) That illness, disease or disability or that state of decline causes
them enduring physical or psychological suffering that is
intolerable to them and that cannot be relieved under conditions
that they consider acceptable; and
(d) Their natural death has become reasonably foreseeable, taking
into account all of their medical circumstances, without a
prognosis necessarily having been made as to the specific length of
time that they have remaining.
1
See reverse to complete the Consultation Assessment Form.
L’évaluation a été effectuée : en personne ou à distance
J’ai fourni au patient une copie du Formulaire NWT8913 –
Possibilité de rétractation, et je l’ai informé qu’il pouvait à
tout moment et de quelque façon, annuler sa demande.
« Problème de santé grave et incurable » – Une personne est affectée
d’un problème de santé grave et irrémédiable lorsque, à la fois :
a) elle est atteinte d’une maladie, d’une affection ou d’un handicap
graves et incurables;
b) sa situation médicale se caractérise par un déclin avancé et
irréversible de ses capacités;
c) sa maladie, son affection, son handicap ou le déclin avancé et
irréversible de ses capacités lui cause des souffrances physiques
ou psychologiques persistantes qui lui sont intolérables et qui ne
peuvent être apaisées dans des conditions qu’elle juge acceptables;
d) sa mort naturelle est devenue raisonnablement prévisible compte
tenu de l’ensemble de sa situation médicale, sans pour autant
qu’un pronostic ait été établi quant à son espérance de vie.
1
NWT8918/0616
The patient meets the following eligibility criteria for medical
They are eligible – or, but for any applicable minimum
period of residence or waiting period, would be eligible –
for health services funded by a government in Canada;
They are at least 18 years of age and capable of making
decisions with respect to their health;
They have a grievous and irremediable medical condition;
They have made a voluntary request for medical assistance
in dying that, in particular, was not made as a result of
external pressure (i.e. completed the Medical Assistance in
Dying – Formal Written Request form NWT8911); and
They give informed consent to receive medical assistance in
dying.
I,
Le patient doit répondre aux critères suivants pour demander
l’aide médicale à mourir :
Il est admissible ou le sera (pour des raisons de délai
d’attente ou de durée de résidence à respecter) aux services
de santé financés par le gouvernement du Canada;
Il est âgé d’au moins 18 ans et est en mesure de prendre des
décisions quant à sa santé;
Il souffre d’un problème de santé grave et incurable;
Il a délibérément demandé l’aide médicale à mourir,
sans pressions extérieures (et il a notamment rempli le
formulaire NWT8911 intitulé Aide médicale à mourir –
Demande écrite officielle du patient);
Il a donné son consentement éclairé de recevoir l’aide
, Je soussigné(e),
(Name of Consulting Practitioner, please print)
(Nom du praticien consultant en caractères d’imprimerie)
state and confirm that I:
déclare et confirme que :
• am not a mentor to, or responsible for supervising the work of, • je ne suis pas un mentor, ni un superviseur de
;
; and
;
• do not know or believe that I am a beneficiary under the will of, • j’ignore et ne crois pas être un bénéficiaire du testament du
or a recipient, in any other way, of a financial or other material
patient, ou de tout autre don matériel ou financier à la suite du
benefit resulting from the death of
décès de
• do not know or believe that I am connected to
or to
;
in any way that affects my objectivity.
Consulting Practitioner Information
Renseignements sur le praticien consultant
Name
Nom
• j’ignore et ne crois pas avoir un lien familial avec
ou
qui influerait le moindrement sur mon objectivité.
,
;
;
;
;
Phone Number of Consulting Practitioner /
Numéro de téléphone du praticien consultant
Assessment Notes (continued) / Conclusions de l’évaluation (suite) :
NWT8918/0616
REFLECTION PERIOD AMENDMENT –
PRACTITIONER
AMENDEMENT À LA PÉRIODE DE
RÉFLEXION DE L’AIDE MÉDICALE
À MOURIR – PRATICIEN
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
I,
, Je soussigné(e),
am of the opinion that the patient’s death, or the loss of their
capacity to provide informed consent, is imminent and that a
shorter period of
(days) is appropriate for providing
suis d’avis que le décès du patient, ou la perte de sa capacité
à exprimer un consentement éclairé, sont imminents, et
qu’il serait approprié d’écourter la période pour avoir l’aide
Practitioner Information / Renseignements sur le praticien
médicale à mourir de
Name
Nom
Phone Number of Practitioner / Numéro de téléphone du praticien
NWT8914/0616
jours.
,
REFLECTION PERIOD AMENDMENT –
CONSULTING PRACTITIONER
AMENDEMENT À LA PÉRIODE DE
RÉFLEXION POUR L’AIDE MÉDICALE
À MOURIR – PRATICIEN CONSULTANT
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
I,
(Name of Consulting Practitioner, please print)
am of the opinion that the patient’s death, or the loss of their
capacity to provide informed consent, is imminent and that a
shorter period of
(days) is appropriate for providing
Consulting Practitioner Information
Renseignements sur le praticien consultant
Name
Nom
, Je soussigné(e),
(Nom du praticien consultant en caractères d’imprimerie)
suis d’avis que le décès du patient, ou la perte de sa capacité
à exprimer un consentement éclairé, sont imminents, et
qu’il serait approprié d’écourter la période pour avoir l’aide
médicale à mourir de
Phone Number of Consulting Practitioner /
Numéro de telephone du praticien consultant
NWT8915/0616
jours.
,
DISPENSING OF MEDICATION
I,
ADMINISTRATION DES MÉDICAMENTS
, Je soussigné(e),
(Pharmacist Name, please print)
(Nom du pharmacien en caractères d’imprimerie)
,
confirm that, before dispensing any medications, I was informed by confirme qu’avant d’administrer les médicaments, j’ai été informé par
that the medication(s) prescribed and listed below are being
prescribed to
que les médicaments indiqués ci-dessous avaient bien été prescrits à
for the purpose of providing medical assistance in dying.
aux fins de l’aide médicale à mourir.
I have dispensed the medications to:
J’ai remis les médicaments à :
Type and form of medication:
Type et forme des médicaments :
.
Pharmacist Information / Renseignements sur le pharmacien
Name
Nom
Signature of Pharmacist / Signature du pharmacien
Nom et adresse de la pharmacie
Phone Number of Pharmacist / Numéro de téléphone du pharmacien
NWT8917/0616
.
CONSENTEMENT EXPRÈS DU PATIENT
DEVANT RECEVOIR L’AIDE MÉDICALE
À MOURIR
EXPRESS CONSENT BY PATIENT
TO RECEIVE MEDICAL ASSISTANCE
IN DYING
Name
Nom
Date of Birth
Date de naissance
Health Care Number
Telephone Number
Address
Adresse
Illness, Disease, or Disability Leading to Request
Maladie, affection ou handicap à l’origine de la demande
I,
made a request for medical assistance in dying on
(Original date of request for medical assistance in dying - D/M/Y)
I made the request voluntarily and not as a result of external
pressure.
,
.
I understand that I can withdraw this request at any time and in
any manner and that I hereby confirm that I have been provided
with the opportunity to withdraw my request.
I hereby request and consent to the provision of medical
Patient Signature
** Witness to Patient Signature
Date - D/M/Y
Date - D/M/Y
Date - D/M/Y
See reverse to complete the Express Consent Form.
Je soussigné(e),
déclare avoir soumis une demande d’aide médicale à mourir le
(Date de la demande d’aide médicale à mourir originelle - J/M/A)
J’ai fait cette demande de manière volontaire et sans pression
extérieure.
,
.
Je comprends que je peux retirer ma demande en tout temps et
par tout moyen, et je confirme, par la présente, qu’on m’a donné
la possibilité de retirer ma demande.
Je demande, par la présente, la prestation de l’aide médicale à
mourir et j’y consens.
Time
Time
* Signature de la personne signant au nom
du patient (si celui-ci en est incapable)
Time
** Témoin de la signature du patient
Date - J/M/A
Date - J/M/A
Date - J/M/A
Heure
Heure
Heure
Pour remplir le formulaire de consentement exprès du patient, voir le verso.
NWT8912/0616
I,
, understand
is making
in dying;
Signature of Person Signing on Behalf of Patient
Date - D/M/Y
that
, understand
has made
NWT8912/0616
Witness Signature
comprends que
,
personne signant en son nom, je confirme que :
mourir;
son nom;
Signature de la personne signant au nom du patient
Date - J/M/A
** Témoin indépendant
in dying;
• I am not directly involved in providing health care services
to the patient making the request; and
the request.
Je soussigné(e),
** Independent Witness
I,
(si celui-ci est incapable de signer – c.-à-d. une personne
autre qu’un témoin)
Phone Number of Independent Witness
Date - D/M/Y
Je soussigné(e),
comprends que
,
mourir;
• je ne suis pas propriétaire ou exploitant d’un établissement
des soins ou d’un établissement où celle-ci réside;
Date - J/M/A
Numéro de téléphone du témoin indépendant
Medical Assistance in Dying
NWT Central Coordinating Services
Toll Free at 1-855-846-9601
Or direct at 1-867-767-9050 Ext. 49008
Monday - Friday: 8:30am - 5:00pm

medical assistance in dying - The Registered Nurses Association of

Transcription

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