Government of Ontario

Ministry of Health


Clinician Aid A
Patient Request for Medical Assistance In Dying

Medical Assistance in Dying means: (a) the administering by a medical practitioner or nurse practitioner of a substance to a person, at their request, that causes their death; or (b) the prescribing or providing by a medical practitioner or nurse practitioner of a substance to a person, at their request, so that they may self-administer the substance and in doing so cause their own death.

Authorized third person is a person who is at least 18 years of age and who understands what it means to request medical assistance in dying and who does not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that person's death may sign and date the request in the presence and on behalf of the person requesting medical assistance in dying.

An independent witness is any person who is at least 18 years of age and who understands the nature of the request for medical assistance in dying who (a) does not know or believe that they are a beneficiary under the will of the person making the request, or a recipient, in any other way, of a financial or other material benefit resulting from that personís death; (b) is not an owner or operator of any health care facility at which the person making the request is being treated or any facility in which that person resides. An independent witness may include a person who is paid to provide health care services or personal care to the person requesting medical assistance in dying. A medical assistance in dying provider, assessor or where applicable, the consulting practitioner with expertise in the condition causing the personís suffering is not permitted to act as a witness.

A person is considered to have a grievous and irremediable medical condition where:

Note: Persons whose sole underlying medical condition is a mental illness, and who otherwise meet all eligibility criteria, are not currently eligible for MAID. The term mental illness does not include neurocognitive or neurodevelopmental disorders, or other conditions that may affect cognitive abilities.

The use of this aid is voluntary. It is being provided to assist you in making a written request for medical assistance in dying that complies with the legal requirements.

Once you complete this request, you should provide it to your doctor or nurse practitioner. The completed aid may be included in your medical records and may be used by your doctor or nurse practitioner to provide health care to you.

Section 1 – Patient Information


Gender


  



Section 2 – Request for Medical Assistance in Dying

You must personally verify all data in this section and sign your own name. If you are unable to sign for yourself you may ask an authorized third person to complete it for you and sign their name in Section 3 under authorized third person signature.


request that a doctor or nurse practitioner help me to die.

I confirm that:



Section 3 – Authorized Third Person (where the person requesting medical assistance in dying is unable to sign and date the request)


Current Address











By signing below on the personís behalf, I declare that:




Section 4 – Witness Present Upon Signing and Declaration of Witness

This section must be completed by one independent witness. An independent witness may include a person who is paid to provide health care services or personal care to the person requesting medical assistance in dying. A medical assistance in dying provider, assessor, or where applicable, the consulting practitioner with expertise in the condition causing the personís suffering is not permitted to act as a witness.

Witness Information


Current Address









Relationship to Person Requesting Medical Assistance in Dying

* Neither myself nor my spouse are beneficiaries under the will of the person making the request, or a recipient, in any other way, of a financial or some other material benefit resulting from that personís death.

By signing below, I declare that:



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3889-22E (2022/10)      © King’s Printer for Ontario, 2022