MAiD Documentation Essentials

Welcome to the MAID documentation hub. Here, nurses and nursing students will find comprehensive resources to deepen their understanding of Medical Assistance in Dying. Explore our content of consciousness checklists and written components to enhance your knowledge and practice in the aspect of documentation.

Why is Documentation so important with MAiD

Nurses involved with MAiD must maintain a thorough understanding of the documentation requirements not only to ensure patients safety but maintain legal requirements including, The Criminal Code of Canada, Provincial legislation along with employer policies. Failure to do so can revoke legal protections, resulting in professional discipline and possible legal repercussions. This will also compromise the patients MAiD orders.

Technical Guidance Document: Reporting requirments under the regulations for monitoring of MAiD

Documentation Role RNs/RPNs

Following CNO Documentation Practise Standards and legislation

Highlighted are key components and best practise following MAiD documentation, to assist in navigating the complex information.

Provided in the link below is an example of a comprehensive checklists.

Comprehensive Checklist examplePDF. Checklist

RN's/RPNs perform a supportive role caring for a patient before, during and after the MAiD process.
Nursese may act as an Indepentant witness, if they meet criteria.
Nurses must document all nursing care provided, conversations regarding MAiD and assessments made in a timely, factual, complete and confidential manner.
Your documentation must show continous assessment meaning you should document everytime a patient exspresses a settled intention or inquiry about MAiD as these are condidered legal triggers in the MAiD process.

RNs/RPNs DO NOT assess eligibility of MAiD.

Nurses must ensure the following are clearly documented

Initial Request Documnet any verbal or written request for information or for MAiD, include the time and the health professional notified.
Consent Document if the patient exspressed thier desire for MAiD voluntarily, without external pressure.
Care Document assessments, any interventions and supports provided to the patient and family.
If a nurse is witness to an independent witness signing a formal request, they are required to document the event.

Nurses do not document the formal eligibility assessments

DO

Chart in a timely manner, as close to real time as possible.
If adding information later, clearly mark "late entery" with current time and date also include date/time of event.
Chart detailed descriptions of patient conversations, comfort levels and any family interventions.

DO NOT

Never alter, delete or add information to empty spaces in patient records.
Avoid shorthand, use complete sentences. Do not use abbrevations. Avoid anything that can be misinterepreted.

Post-Procedure Document the time of death (as confirmed by the NP or Physician) Include any care provided post mortem.

Coroner Notification- A nurse can only document that a cornor was notified. In accordance with the Corner's Act.

Nurses do not document the administration of MAiD substances (medication) that is soley the responsability of the provider.

Conscientious Objection Nurses have the legal right the refuse partcipating in MAiD. This must be documented and a plan for safe patient ttransfer must be recorded to avoid patient abandonment.

Liability Protection: Accurate documentation is the primary defense for a nurse to avoid failure to comply with legal requirments which can lead to criminal charges.

Further information regarding Rights and Protections

Discontinuing or refusing to provide care

Enhance your MAiD Education

Yes. RNs/RPNs involved in MAiD may be a independent witness, Per Bill C-7. Nurses may act as a witness if the provision of care is thier primary occupation. A Independant witness purpose is to confirm the idenity of the individual requesting MAid and verfy they are signing voluntarily.

Providers must NOT:

Be a medical provider who is involved in MAiD assessment or providing care (eg Nurse preactioner, Physician)
Be a known or suspected beneficary of the patient. Cannot be a financial or material recepient resulting from patients death.
Be a owner or operator of a health care facility where the patient is being treated or resides.

In Onatrio a nurse has a right to a Conscienctious Objection regarding MAiD. Under federal ligislation and provincial regulations. You cannot be compelled to perform or assit in the procedure if it conflicts with moral or religious beliefs. The objection must be documented and "effective transfer of care" to another nurse ensuring the patients safety and clinical needs are continuously met.

You CANNOT refuse

Emergency care if a patient is in a life threatening situation un related to MAiD
Information, avalibilty of MAiD or the process for requesting it.

NO Nurses are not reqiured to document any aspect of the MAiD procedure including documenting the administartion of the medication. That is the responsability of the NP or physician. You document what care you provided personally and all relevant communications.

For additional Questions or clarification

Coffee Chat with CNO: Documentation Standards