Question Period Note: Health Canada Releases the Fourth Annual Report on Meducal Assistance in Dying in Canada

On October 24, 2023, Health Canada released the Fourth Annual Report on Medical Assistance in Dying in Canada (2022) containing data that provide insights into written requests for MAID and the delivery of MAID in Canada during 2022.
In 2022, the number of cases of MAID grew by 31.2% over 2021. MAID accounts for 4.1% of all deaths in Canada in 2022. All provinces except Manitoba and the Yukon continued to experience a steady year-over-year growth in 2022.
The release of the Fourth Annual Report on Medical Assistance in Dying in Canada may increase attention to MAID and the safety concerns raised by certain groups regarding MAID implementation, and the lifting of the exclusion of MAID for people whose sole medical condition is a mental disorder (MD-SUMC) on March 17, 2024.
On February 2, 2023, the Government of Canada introduced legislation, former Bill C-39, to extend the exclusion of eligibility for MAID where a person's sole underlying medical condition is a mental illness for an additional year, until March 17, 2024. Bill C-39 received Royal Assent on March 9, 2023.

MAID monitoring and reporting is critical to ensuring transparency and fostering public trust in how MAID is being implemented.
This annual report represents the collaborative efforts of all levels of government and health professionals working together to provide a comprehensive picture of the implementation of MAID in Canada.
Our Government continues to work closely with the provinces and territories and their health stakeholders to support the development and uptake of resources, such as a Model MAID practice standards and an accredited MAID curriculum, in order to enable safe access to MAID for people who suffer solely from a mental illness.
IF PRESSED ON THE FOURTH ANNUAL REPORT ON MAID IN CANADA…
The fourth annual report is based on reporting requirements from the 2018 Regulations for the Monitoring of MAID, and contains data that provide insights into requests for MAID and the delivery of MAID in Canada during 2022.
Data collection has since been expanded after new Regulations came into force starting in 2023, but data for 2023 will only be available and reported in 2024.
IF PRESSED ON THE INCREASING MAID DEATHS IN CANADA…
In 2022, 96.5% of MAID provisions were for individuals where death was reasonably foreseeable, providing compassionate care at the end of life.
The proportion of MAID recipients whose natural death was not reasonably foreseeable continues to remain very small compared to the total number of MAID recipients, representing just 3.5% of all MAID provisions and only 0.14% of all deaths in Canada.
IF PRESSED ON THE EXTENSION OF THE TEMPORARY EXCLUSION …
Our Government extended the exclusion of eligibility for MAID for persons suffering solely from a mental disorder to allow for the dissemination and uptake of key resources by clinicians, including a Model Practice Standard, an Advice to the Profession document, several knowledge exchange meetings, and a national accredited MAID curriculum.
We understand this is a complex issue with many diverging views.
Our Government continues to work closely with the provinces and territories and their health stakeholders to support the development and uptake of these resources for safe access to MAID for people who suffer solely from a mental illness.
IF PRESSED ON THE QUESTION OF MAID FOR PEOPLE WITH MENTAL ILLNESS AS THE SOLE UNDERLYING CONDITION …
The Government recognizes that mental disorders can cause suffering on par with that of physical illnesses.
The Government also recognizes that there are diverse views on MAID and mental illness within the psychiatric community.
Resources such as the Model MAID Practice Standard, Advice to the Profession, the MAID training curriculum, and additional resources developed by provinces and territories will support the medical and psychiatric communities in delivering MAID for complex cases.
IF PRESSED ON THE MAID FOR MENTAL ILLNESS AND SUBSTANCE USE …
MAID is an option that is available only for eligible Canadians, and the legislation sets a high bar with stringent eligibility criteria and robust procedural safeguards. The MAID provisions in the Criminal Code are carefully designed to protect vulnerable people including those suffering from mental disorders including substance use.
The Government has provided significant funding to support mental health and substance use supports and to develop national standards for substance use services.
IF PRESSED ON CONCERNS THAT PEOPLE WILL SEEK MAID AS A FORM OF SUICIDE, ESPECIALLY THOSE WITH A MENTAL ILLNESS …
The legislation sets a high bar for access. Only individuals with severe, long-standing and treatment-resistant mental illnesses will be considered for MAID.
The Model MAID Practice Standard indicates that assessors and providers should ensure that a person’s request is consistent, unambiguous and rationally considered during a prolonged period of stability, and not during a time of crisis or suicide ideation.
The Government has provided significant funding to support the launch and implementation of 9-8-8, a three-digit number for suicide prevention and emotional distress.
IF PRESSED ON THE GOVERNMENT’S REACTION TO MEDIA STORIES ALLEGING THAT PEOPLE ARE SEEKING MAID DUE TO LACK OF NEEDED SERVICES
The eligibility criteria and robust safeguards provided by the law set a very high bar for accessing MAID.
Improving access to social and health services remains a priority and governments are working hard to address disparities.
For example, the Government has introduced Bill C-22, the Canada Disability Benefit Act to reduce poverty and support financial security of persons with disabilities. This legislation received Royal Assent on June 22, 2023.
IF PRESSED ON CONCERNS THAT PEOPLE WILL SEEK MAID DUE TO STRUCTURAL VULNERABILITY…
The legislation sets a high bar for access. Only individuals with a serious illness, disease or disability, that are in an advanced state of decline that cannot be reversed and experience unbearable physical or mental suffering will be considered for MAID.
While structural vulnerability may exacerbate a person’s suffering, MAID eligibility is determined by an assessment of the consequences of the person’s medical condition and whether or not the person, as a result, is experiencing enduring and intolerable physical and psychological suffering.

MAID MONITORING AND REPORTING
The federal MAID monitoring system was established in 2018 through the Regulations for the Monitoring of Medical Assistance in Dying and provides a robust framework for the collection, analysis and reporting of information. The existing Regulations enable Health Canada to identify and monitor trends in the delivery of MAID in Canada and assist in supporting transparency and fostering public trust in the MAID legislation and its application. Data collected from individual MAID providers or from a recognized PT authority is verified and analyzed by Health Canada, before being published in the annual report. The Fourth Annual Report on Medical Assistance in Dying, published on October xx, 2023, highlighted the following key findings:
In 2022, there were 13,241 MAID provisions reported in Canada, accounting for 4.1% of all deaths in Canada, and a growth rate of 31.2% over 2021. 3.5% of the total number of MAID provisions (463 individuals), were individuals whose natural deaths were not reasonably foreseeable. The average age of individuals at the time MAID was provided in 2022 was 77.0 years with cancer (63.0%) cited as the most common underlying medical condition (63.0%). A slightly larger proportion of males (51.4%) than females (48.6%) received MAID in 2022, a result consistent with previous years. The majority of MAID recipients (77.6%) had received palliative care in 2022, and of the MAID recipients who did not receive palliative care (19.6%), 87.5% had access to these services. Private residences continue to be the primary setting for the administration of MAID in Canada. 18.6% of written requests in 2022 resulted in an outcome other than MAID: 298 individuals withdrew their request (1.9% of written requests); 560 individuals were deemed ineligible (3.5% of written requests); and 2,144 individuals died prior to receiving MAID (13.3% of written requests).
On January 1, 2023, the amended Regulations for the Monitoring of Medical Assistance in Dying came into force to enhance data collection and reporting through the federal MAID monitoring system. Data collected under these amended regulations now includes, among other things, information related to race, Indigenous identity, and disability of those seeking MAID. This new information will be reflected in the annual report on MAID in Canada for the calendar year 2023, to be publicly released in 2024.
MAID LEGISLATION IN CANADA
MAID legislation has evolved since 2016 (former Bill C-14). In 2021, former Bill C-7 repealed the provision that requires a person’s natural death be reasonably foreseeable in order to be eligible for MAID, although the repeal excluded eligibility for persons whose sole underlying condition is a mental illness (MI-SUMC) until March 17, 2023.
This two-year exclusion allowed time to initiate an expert review respecting recommended protocols, guidance and safeguards to apply to requests for MAID by persons who have a mental illness as a sole underlying condition. The work was undertaken by a Government-appointed Expert Panel on MAID and Mental Illness (the Panel). The Panel’s Report was tabled in Parliament on May 13, 2022.
On March 9 2023, the Government passed legislation (former Bill C-39) that further delayed the repeal of the above MI-SUMC exclusion, adding an additional year to allow more time for dissemination and uptake of key resources by the medical and nursing communities. The delay ends on March 17, 2024, The additional time also allowed for jurisdictions to plan, develop and be ready to implement processes and supports for MAID requests involving mental illness.
THE EXPERT PANEL ON MAID AND MENTAL ILLNESS
Former Bill C-7, which received Royal Assent on March 17, 2021, included a sunset clause excluding persons with a mental illness as a sole underlying medical condition from seeking MAID until March 17, 2023. During the two-year exclusion period, the Ministers of Health and Justice were required to launch an independent expert review on the topic of MAID and mental illness.
An Expert Panel was appointed by Ministers of Justice and Health to conduct an independent review to consider protocols, guidance and safeguards to apply to MAID requests by persons who have a mental illness. The final report of the Expert Panel on MAID and Mental Illness was tabled in Parliament on May 13, 2022. It included 19 recommendations that provide guidance on the interpretation of the MAID eligibility criteria, the application of the legislated safeguards, and the assessment process, as well as advice on measures to improve the functioning of Canada’s MAID regime more broadly.
A key conclusion of the Panel was that, the existing MAID eligibility criteria and safeguards, when interpreted appropriately and buttressed by existing laws, standards, and practices in related areas of healthcare, can provide an adequate structure for assessing those more complex (track two) MAID requests, including where a mental disorder is the sole underlying medical condition.
On July 26, 2022, the Ministers of Health, Justice and Disability Inclusion issued a news release on the Government’s progress in implementing several of the Panel’s key recommendations to help prepare the MAID practice community in assessing these complex MAID requests. This progress included: developing a practice standard for MAID; development of a nationally fully accredited MAID curriculum; enhancements to the data collection system under the Regulations for the Monitoring of MAID; plans for Indigenous engagement; and, federally-funded qualitative research on MAID.
PARLIAMENTARY REVIEW OF MAID LEGISLATION
The 2021 legislation also required that a Parliamentary Review be initiated to address the topics of mature minors, advance requests, mental illness, the state of palliative care in Canada, and the protection of Canadians with disabilities.
The Special Joint Committee on MAID (AMAD) submitted an interim report in June 2022, specifically focused on MAID where a mental disorder is the sole underlying medical condition. The interim report made no formal recommendations but urged the federal government to support the timely implementation of the recommendations of the Expert Panel.
AMAD’s final report, containing 23 recommendations on all topics under its remit, was tabled on February 15, 2023. On June 15, 2023, the Government tabled its Response to AMAD’s report and recommendations in the House of Commons.
It is anticipated that AMAD will reconvene in 2023 for further study.
PREPAREDNESS FOR THE REPEAL OF THE CLAUSE ON THE EXCLUSION OF MENTAL ILLNESS
On March 9, 2023, the Government of Canada passed legislation to extend the temporary exclusion of eligibility for persons suffering solely from a mental illness from March 17, 2023 to March 17, 2024. While the Government, in collaboration with provinces and territories, and their medical communities had made important progress in preparing for the original March 2023 deadline, the additional year allowed more time for dissemination and uptake of key resources by the medical and nursing communities.
In September 2022, Health Canada convened an independent MAID Practice Standards Task Group, comprised of individuals with clinical, regulatory, and legal expertise, to develop a practice standard to provide regulators and clinicians with guidance on MAID assessments for complex requests, including those that involve mental disorders. The Model MAID Practice Standard was published on March 27, 2023, along with another document, Advice to the Profession, which provides more detailed clinical advice on challenging topics than is typically included in a regulatory practice standard.
On September 13, 2023 the Government announced the launch of the first nationally accredited bilingual MAID education program (developed by the Canadian Association of MAID Assessors and Providers) available to licensed physicians and nurse practitioners. It consists of seven modules addressing various topics related to the assessment and provision of MAID, including mental disorders and other complex chronic conditions. Six of the seven modules are currently available for registration, the full program will be available by the end of 2023.
Health Canada continues to work with provinces and territories to support system and clinician preparedness for mental illness eligibility and is supporting research initiatives targeting marginalized/underserved populations and knowledge gaps in MAID implementation and delivery.

On October 24, 2023, Health Canada released the Fourth Annual Report on Medical Assistance in Dying in Canada. This report provides aggregate information on people in Canada who have made a written request for medical assistance in dying (MAID) and the outcomes of those requests, including those who received MAID in 2022.
Federal reporting provides a clear picture of the current state of MAID across Canada: who is requesting MAID, the reasons for these requests, and the circumstances under which it is provided or isn’t provided.
Growth in MAID provision has increased steadily each year as a result of awareness and acceptance of the practice.
The Fourth Annual Report on Medical Assistance in Dying in Canada reported that the vast majority of 2022 MAID provisions (96.5%) were for individuals where death was naturally foreseeable, providing compassionate care at the end of life.
The proportion of MAID recipients whose natural death was not naturally foreseeable continues to remain very small compared to the total number of MAID recipients, representing just 3.5% of all MAID provisions and only 0.14% of all deaths in Canada.
This year, a number of important initiatives have been launched to support the evolution and practice of MAID generally and to support the health system’s preparedness for the lifting of the temporary exclusion of MAID eligibility for persons suffering solely from a mental illness in March 2024.
Guided by the recommendations from the Expert Panel on MAID and Mental Illness, the Government of Canada has:
o Developed a model MAID Practice Standard designed for use by regulatory bodies and clinicians in addressing complex requests for MAID, including where mental illness is involved (completed March 2023).
o Developed and launched (August 2023) a nationally accredited MAID Training Curriculum.
o Funded a Knowledge Exchange Workshop (June 2023) that included over 40 MAID practitioners as well as psychiatrists from across Canada to discuss roles and contributions to the proper assessment and management of MAID where mental disorders are involved, and supported local training related to MAID for mental disorders.
o Amended the Regulations for the Monitoring of MAID in Canada to enhance data collection and enrich research and analysis and reporting back to Canadians (enacted January 1, 2023 with new data to be reported in 2024).
o Initiated early activities on engagement with Indigenous Peoples (online tool launched August 17, 2023, with other Health Canada-led and Indigenous-led activities planned for 2024).
Provinces and territories, in collaboration with regulators and MAID communities, have also been working towards preparedness – some creating specific teams, adding resources, updating their practice standards and encouraging training to help clinicians in addressing requests for those more complex MAID cases, and where mental illness is a sole underlying medical condition.