The details of a MAID assessment are often misunderstood and, far too often, misrepresented in the media or by organizations that do not agree with Canada’s legal assisted dying legislation. We asked Dr. Chantal Perrot to outline in detail what she needs to know in order to make a decision about a patient’s eligibility for MAID. 

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The MAID assessment process is rigorous and detailed and has several components. 

There are as many different MAID assessments as there are individuals requesting MAID, but there are some basic principles and guidelines that are common to all of them.  

Any person receiving MAID must meet all the eligibility criteria as detailed in the Criminal Code: 

241.2  

(1) A person may receive medical assistance in dying only if they meet all of the following criteria: 

(a) 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; 

(b) they are at least 18 years of age and capable of making decisions with respect to their health; 

(c) they have a grievous and irremediable medical condition; 

(d) they have made a voluntary request for medical assistance in dying that, in particular, was not made as a result of external pressure; and 

(e) they give informed consent to receive medical assistance in dying after having been informed of the means that are available to relieve their suffering, including palliative care. 

Grievous and irremediable medical condition:  

(2) A person has a grievous and irremediable medical condition only if they meet all of the following criteria: 

(a) they have a serious and incurable illness, disease or disability; 

(b) they are in an advanced state of irreversible decline in capability; and 

(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. 

When preparing for and doing a MAID assessment, I keep two main goals in mind, one, to get to know the person as well as I can, to understand the underlying values   and principles which guide them in life and what has brought them to seek MAID, and two, to determine whether they meet the above eligibility requirements. 

And probably in that order. 

After receiving the referral, which usually has scant information, I contact the patient, confirm that they would like to meet with me for the purpose of having a MAID assessment, ask a few questions about the medical condition leading them to request MAID, ask for their permission to review any medical records which are on the provincial EMR (electronic medical record), and set a date for us to meet.  

If possible, I prefer to meet people in person, in their homes. I find seeing and being with a person gives me information (e.g., body language, subtle glances, facial expressions, etc.) and insight which can inform my questioning and clinical impressions and which I might not otherwise get with a virtual assessment meeting. It also lets me see how they are living and managing in their own circumstances, which is important information. I let them know that they are welcome to have others present during the interview, but that at one point I will ask to be with them alone, to ask a specific set of questions. 

Before meeting with the patient, I review whatever medical documentation I can find so I can tailor my assessment interview questions to their particular circumstances. 

When we meet, whether in person or by videoconference, I introduce myself and give them my contact information. I ask to see a piece of photo ID, usually a health card, to confirm their identity, their age, and their eligibility for government-funded health services. If they do not have a photo health card, I ask to see their health card and a driver’s license or passport, even if these latter documents have expired. I then ask them and any accompanying family or friends if they have any questions they would like to ask before I start, and I let them know that I will be asking a lot of questions, many of a very personal nature which may feel intrusive. I also tell them that the meeting will take 1-2 hours, and that if at any point they are too tired to continue, we can pause and reschedule to complete the interview.  

I usually start my interview questions by asking if there is anything they would like me to know about them which would help me to give them the best care I can and the care that they want.  

I go on to ask:  

• When did you last feel completely well, like the [person’s name] you knew and loved being? 

• What has changed since then? 

• How do you understand what has happened to you, to your body? 

I follow this with detailed questions about their medical history – past and present – and specifically about the condition(s) with which they are currently living, and which are leading to their request for MAID.  

I ask about their symptoms, what treatments they are currently receiving, what treatments they have already tried, and which treatments remain which they have been offered and are considering or have rejected. 

I explore what their current suffering is, asking them to talk to me about what makes it intolerable to them. I remind them that I need to know what they are living with, what they are experiencing, and ask them to “tell it like it is” for them, to not mask it. When people answer, “Oh, it’s not intolerable,” I ask them, “Then why am I here? Why do you want MAID?” They then speak volumes about what I would call suffering. When I point this out, they invariably talk about how this has become essentially normal for them, they have had to tolerate the intolerable because there was no choice, and they don’t remember a time when they didn’t feel this way. 

Many people are stoic. People are proud. They don’t want to air their dirty laundry or show what they see as weakness. They have been trained to put their best foot forward, to “dress up” for the doctor. You don’t reach a certain age without having suffered the slings and arrows of misfortune along the way. Part of my job is to draw this out, to encourage people to be frank with me and not hide what they are going through. This is surprisingly difficult for many, making it appear to the casual observer that they are “fine,” when that could not be further from the truth. 

I ask detailed questions about their personal history:  

• Where were they born?  

• Where did they grow up?  

• Who are the important people (and pets) in their lives?  

• What has their journey through life been, bringing them to where they are today?  

I ask detailed questions about their interest in, knowledge about, and request for MAID: 

• When did you first think about MAID as something you might like for yourself? 

• With whom have you spoken about your wish to receive MAID? 

While alone with the patient I explore for vulnerabilities, asking questions like:  

• Is anyone pressuring or coercing you into choosing to die now? (I approach this from several vantage points throughout the interview to assure myself that this is the patient’s request, and theirs alone.) 

• Does anyone in your family object to your request for MAID?  

• Do you have a will and powers of attorney?  

• What are your sources of income and debt?  

• Are financial concerns in any way contributing to your request for MAID?  

Interestingly, most people comment that, “Even if I had a million dollars,” it would not give them back their health or be enough for them to want to continue living with their condition(s). 

I also ask:  

• What would you need in order to want to continue to live?  

• What would you need in order to live well?  

• What would lead you to change your mind and not want MAID? (The answer is usually, “A miracle.”)  

• Why are you asking for MAID now, and not three months ago or three months from now? 

I explore the Activities of Daily Living (ADLs) and Independent Activities of Daily Living (IADLs) to learn which they can do on their own, what kind of effort is required of them to do so, and for which ones they need assistance, and how much. Examples of ADLs are walking, grooming, bathing, feeding, toileting, and transferring. IADLs include using the telephone, using a computer or tablet, managing finances, meal preparation, shopping, transportation, housekeeping, and organizing medications. 

I ask about their participation or interest in palliative care, their personal goals of care, where they would like to live their last days and where they would prefer to die. 

I ask about supports: what they need, what they have in place, and what may be lacking. It is important to note that while lack of social supports – whether income supports, housing, disability supports, or mental health supports – contributes to the person’s lived experience, that lack, alone, does not and cannot qualify someone for MAID. Likewise, wishing to not be a burden on family, friends, the health care system, society, etc., or not wanting to spend one’s savings on ongoing care, all may contribute to a person’s experience of their condition and to their suffering, but they are not, in and of themselves, reasons to be found eligible for MAID.  

Part of my job as an assessor is to determine, with the patient, how much these issues may be contributing to the request for MAID and whether any additional help or support may make a significant enough difference that the person would no longer wish to die. 

I ask:  

• What did you used to be able to do or enjoy that you can no longer do?  

• What do you want to do or get done before you die or become more disabled?  

• What is most important to you in your life now? (Most say, “MAID”)  

• What are you most afraid of? (Most say either, “I’m not afraid of anything,” or “I’m afraid of having to continue to live.”)  

• Do you have a religion or faith/belief system which is important to you? 

I explore for any psychiatric history, looking particularly to determine whether depression or any disorder of thought may be contributing to their request for MAID. In the early years of doing assessments, I encountered more than a few people with no previous history of depression or suicidality who had tried to take their own lives due to the intolerable suffering and the despair about it never ending. They did not know that MAID had become legal in Canada and that they could have applied for and been eligible for MAID. While this still happens occasionally, it is, fortunately, much less common. 

Throughout the interview there are opportunities for people to ask questions and opportunities for me to explain more about MAID, about treatment options, about end-of-life care in general, about Advance Care Planning, funeral planning, preparing for the day of MAID, etc. 

I close my questions by asking, “Is there anything we have not talked about today which you think is important for me to know?” followed by, “Do you have any questions for me?” 

In many cases, after the assessment interview and reviewing medical documentation, I have enough information to form an opinion about eligibility. If it is clear to me that someone is eligible or not eligible, I will say so at the time. If it is not clear, and I need to do more research or gather more medical documentation or consult a clinician with expertise I do not have, I tell them it will take more time and that I may need a follow up meeting with them, and/or phone calls and emails. This is particularly true for those who would, once found eligible, be placed on Track 2, people whose deaths are not reasonably foreseeable. While one of the legal safeguards for someone on Track 2 is a mandatory 90 clear days between the start of an assessment and when MAID may be provided, these assessments may take longer and they frequently involve multiple in-person, video, and phone visits, as well as email exchanges. This also helps me see that the request for MAID remains consistent over time, as well as giving me the opportunity to collect the information I need to make my determination about eligibility. 

Only once, in hundreds of assessments, have I found someone ineligible because of coercion to receive MAID. This was a person living with cognitive decline whose spouse was the primary caregiver, and who was not coping. What may come as a surprise, is that I have seen many more cases of coercion not to receive MAID, in which people felt pressured, shamed or guilted to not choose or follow through with MAID. 

With patients who have already signed the written request form, I explore the voluntariness of the request and the independence of the witness to their signature. For those who have not yet signed it, I explain to them what it is and how to fill it out, stressing the importance of the independent witness actually watching them put pen to paper to sign. I also let them know that I will be contacting the witness to confirm this. I generally suggest signing this form earlier rather than later in the assessment process and keeping it in a safe place to be given to me at the time MAID is to be done, if it comes to that. Likewise, I usually suggest having the mandated second independent assessment done earlier rather than later, so the person has the benefit of having this fundamental but often onerous step completed before their condition deteriorates further. 

At the end of the meeting, after I have answered any questions they may have, I ask them the demographic questions which Health Canada requires, letting them know why the questions are asked, that they do not have to answer them, and whether they answer or not does not affect their eligibility or my care. Most people find the questions odd, particularly the ones about sex at birth and gender, but most are willing to answer. 

I ask if the person would like me to explain the MAID procedure itself and what happens on the day of MAID. Sometimes they request that this happen at a later time.  

I inform them that their request for MAID may be withdrawn at any time, up until they receive the first medication. In fact, I remind people of this several times throughout the MAID assessment process, as well as on the day they are to receive MAID.  

I inform them that in most cases they must be capable of giving consent on the day of MAID, and why this may or may not be likely to be an issue for them. If it is likely to be an issue, this warrants a further discussion about capacity and the Waiver of Final Consent which may be written with patients whose deaths are reasonably foreseeable and who are prepared to set a date for MAID.  

I inform them that they must make body disposition arrangements with a funeral home prior to the day of MAID and ask them to let me know whom they have designated to phone the funeral home after death. I also inform them that all deaths by MAID must be reported to the Office of the Chief Coroner of Ontario and that the Coroner Investigator will ask to speak with a family member or friend at some point in the days following MAID. I ask for contact information for this person so I may give it to the Coroner’s Office. 

As I’m listening to patients respond to my questions, I have a number of questions running through my mind for myself, including:  

• Does this person have the requisite capacity to consent to MAID? Are they capable of making decisions regarding their health, including MAID? 

• What role might race, culture, or their background play in this person’s lived experience and request for MAID?  

• What social or economic factors might be contributing to this person’s request for MAID?  

I think about these to try to contextualize their particular request in their particular circumstances. If needed, I will explore these further in a frank conversation with the patient.  

If there are any difficulties with communication, for example if the person does not speak English or if there are cognitive or other issues, I use additional supports to carry out the interview.  

If I am concerned about capacity, I will do a more in-depth capacity assessment myself or refer to someone with greater expertise, as needed. 

How do I determine that a person has a grievous and irremediable medical condition? All 3 sub-criteria for this eligibility requirement must be met. First, they must have an incurable illness, disease, or disability. They must be in an advanced state of irreversible decline in capability. And their suffering from the illness, disease, disability or decline must be intolerable to them and not able to be relieved under conditions they find acceptable.  

This is quite straightforward for someone living with an advanced stage of cancer, who is virtually bedbound, and whose physical pain or existential suffering is intolerable to them and not able to be satisfactorily relieved. 

It may be more complex and challenging to determine for someone who appears to some people to be coping or managing in spite of their diagnosis, decline, and suffering, or for someone whose death is not reasonably foreseeable and for whom there may be further treatments available that could potentially relieve some of their suffering, even if not bring about a cure. Adding even more complexity to these assessments is trying to balance an individual patient’s autonomy and express request for MAID with protection of vulnerable populations and determining whether or not an individual patient is vulnerable to the point of needing protection. For me, these determinations are made in collaboration with the patient; for some clinicians, at least some of these determinations are seen as “objective” to be determined by them, and there isn’t always agreement amongst clinicians or between clinicians and patients.  

By the end of my assessment, I generally have a good understanding of the person, their situation, their guiding values and principles, what is important to them, how they are suffering, why they want to die, and why they no longer wish to pursue further medical treatments. I have the information I need to determine whether they meet each of the eligibility criteria outlined in the Criminal Code.  

As noted earlier, my assessment is significantly guided by having to address these eligibility criteria in the unique circumstances of each patient’s life and circumstances. Since this is a matter of life and death, and since once MAID has taken place there is no going back, assessors want and need to be very sure in their minds that a person meets the eligibility requirements and that they can explain and document why and how they came to their finding of eligibility. 

A finding of eligibility for MAID often comes as a great relief to patients, and a finding of ineligibility is often quite devastating. Whatever the outcome, people may need and want further support. 

Being eligible for MAID does not obligate one to proceed with or book a date for MAID. What it means is that they know they are eligible. They can then stay in touch with me, I can update the assessment periodically, and they can set a date for MAID if it is ultimately desired. 

Some people never have MAID, and die naturally, though they live more comfortably knowing that they could have it. Others carry on until their symptom burden becomes great enough that they don’t want to do so any longer, and they can then have MAID after a brief update of the assessment. 

The MAID assessment interview is documented in detail both during and after the meeting. I include in the medical record, as well, details of phone conversations, email exchanges, conversations with any consultants, conversations with family or friends, etc. This documentation tells the patient’s story – often including their own words – which is essential to formulating and defending my ultimate finding of eligibility or ineligibility for MAID. 

Each patient is unique, each situation is unique. While having templates or guidelines is extremely useful, each determination of eligibility is done on a case-by-case basis taking into consideration the totality of the particular person’s circumstances.  

In order to do a proper MAID assessment, I need to show people in a short period of time that they can trust me, that I deserve their trust. They need to see and feel that I believe them, that I will take them seriously, and that I will not dismiss their concerns. I want them to see that I will do my job thoroughly and that I will do my best to advocate for them and their wishes. It is a great privilege to be welcomed into the lives of people at this juncture of their lives. I am deeply humbled by the trust they place in me and by their willingness to share such deeply intimate details of their lives with me.