Organ and Tissue Donation after Medical Assistance in Dying: Guidance for Policy Update Forum

Deceased organ and tissue donation after medical assistance in dying and other conscious competent donors: guidance for policy update

Updated guidance in CMAJ (Canadian Medical Association Journal) helps clinicians navigate the challenges in supporting patients who choose organ and tissue donation after medical assistance in dying (MAiD). 

Deceased organ and tissue donation after medical assistance in dying: 2023 updated guidance for policy  Kim Wiebe, Lindsay C. Wilson, Ken Lotherington, Caitlin Mills, Sam D. Shemie and James Downar; for the Organ and Tissue Donation After Medical Assistance in Dying – Guidance for Policy forum participants  CMAJ June 26, 2023 195 (25) E870-E878; DOI: https://doi.org/10.1503/cmaj.230108

The updated guidance includes 8 new and 2 updated recommendations in addition to the original recommendations, many of which are still current. It applies to conscious, competent patients, including those whose natural death is not reasonably foreseeable (Track 2 patients), a new category now eligible from Bill C-7.

• Though many of the recommendations from the guidance developed in 2019 are still relevant, this guidance provides 2 updated recommendations and 8 new recommendations in the following areas:
  • referral to an organ donation organization,
  • consent,
  • directed donation,
  • MAiD procedures,
  • support for health-care professionals, and
  • reporting.

Why did the guidance need to be updated?

This updated guidance seeks to ensure policies and practices for organ and tissue donation following MAiD in Canada are aligned with current Canadian legislation. This will help clinicians navigate the medical, legal and ethical challenges that arise when they support patients pursuing donation following MAiD.

Background

In 2019, in collaboration with the Canadian Critical Care Society, the Canadian Society of Transplantation, and the Canadian Association of Critical Care Nurses, Canadian Blood Services published the first guidance document for organ donation after MAiD; Organ and Tissue Donation for Medical Assistance in Dying and Other Conscious Competent Patients: Expert Guidance for Policy,The development of this guidance began in 2017 by hosting a two-day consensus forum in response to patient-initiated and practitioner requests for guidance on donation after medical assistance in dying (MAiD). Medical, legal and ethical experts, as well as patient and family partners, were brought together and developed recommendations to help organ and tissue donation organizations, administrators, policy makers, and health care teams navigate clinical issues surrounding organ and tissue donation by patients who choose to donate their organs and tissues after MAiD or the withdrawal of life-sustaining measures (WLSM).

The 2019 publication makes several key recommendations, including:

• Protection for patients–the decision to have MAiD or withdrawal of life-sustaining measures must occur before any discussion of organ and tissue donation.
• Choice–medically suitable conscious competent patients who provide first-person consent to end-of-life procedures should be given the opportunity to donate organs and tissues.
• Consent–the patient must be able to provide first-person consent and be able to withdraw consent for MAiD or donation at any time.
• Donor testing–physicians, transplant teams and other staff should try to minimize the impact and disruption of donating (such as testing) for the patient.
• Determination of death–the dead donor rule must be respected, meaning vital organs and tissue can only be removed from deceased donors after determination of death according to accepted criteria.
• Conscientious objection–health-care professionals may choose not to participate in MAiD or withdrawal of life-sustaining measures, but they should work to support the patient’s wishes to donate. To date, there have been many instances in which conscious, competent patients have successfully donated their organs and tissue following MAiD or WLSM across Canada, resulting in more lives saved.

Updates to the medical assistance in dying legislation

In October 2020, the Quebec Superior Court found that one of the eligibility criteria outlined in Bill C-14 (initially introduced in 2016) was incompatible with the original decision of the Supreme Court of Canada. Accordingly, the Minister of Justice and Attorney General of Canada introduced Bill C-7, which proposed a series of changes to the Criminal Code’s provisions on MAiD to align with this decision, and to address additional concerns with the procedures outlined in the original Bill C-14. The proposed changes follow extensive consultations with Canadians, experts, practitioners, stakeholders, Indigenous groups, provinces and territories, and an online questionnaire that received over 300,000 responses.

In summary, the Bill proposed the following Criminal Code amendments to the MAiD regime:

• Eligibility criteria–repeal the “reasonably foreseeable natural death” criterion butexclude cases where mental illness is the sole underlying medical condition;
• Safeguards–create two sets of safeguards − one set of eased safeguards for people whose natural death is reasonably foreseeable, and a second set of new and clarified safeguards for people whose natural death is not reasonably foreseeable;
• Advanced consent–waive the requirement for final consent at the time of the MAiD procedure for persons whose natural death is reasonably foreseeable and who have been assessed and approved for MAiD if they lose capacity to reaffirm consent before their scheduled date for MAID and have a written arrangement with a practitioner; and permit advanced consent to the administration of MAiD by a practitioner in cases of failed self-administration;
• Monitoring regime–enhance the reporting requirements based on experiences with the federal MAiD monitoring regime to date. Bill C7 was adopted on March 17, 2021 and these proposed legislation changes have come into force across Canada.

Guidance for policy update published in 2023

In response to the legislation changes outlined above, Canadian Blood Services assembled a group of medical, legal and ethical experts, as well as patient and family partners, to examine the legislation changes and  impact on organ and tissue donation practices. Through a series of meetings,  the group examined the potential impacts of advanced consent and loss of capacity prior to MAiD and donation. The group also discussed the impacts on donation after MAiD for Track 2 patients. MAiD eligibility was not in scope. The group also used this opportunity to examine other emerging issues related to MAiD and donation, including directed donation, donation following MAiD at home, national data collection, knowledge gaps and future research questions.

An executive summary from one of the focused groups held on June 21, 2021 is available here. A pdf copy is available upon request in English and French. Contact otdt@blood.ca to request the full report. 

For additional information If you have any questions or require further information, please contact otdt@blood.ca.

Related publications

Deceased organ and tissue donation after medical assistance in dying: 2023 updated guidance for policy  Kim Wiebe, Lindsay C. Wilson, Ken Lotherington, Caitlin Mills, Sam D. Shemie and James Downar; for the Organ and Tissue Donation After Medical Assistance in Dying – Guidance for Policy forum participants  CMAJ June 26, 2023 195 (25) E870-E878; DOI: https://doi.org/10.1503/cmaj.230108

Downar J, Shemie SD, Gillrie C. Deceased organ and tissue donation after medical assistance in dying and other conscious and competent donors: guidance for policy. CMAJ 2019 June 3;191:E604-13. doi: 10.1503/cmaj.181648