Quebec's Right-to-Die Law as of April 2016

The complete text of this law (in English) appears after these introductory comments.


An Organized List of the Safeguards Embedded in
"An Act Respecting End-of-Life Care"

    The following 17 Safeguards for life-ending decisions
are highlighted in the text of the law below.
But because they are scattered thru-out the law,
it make more sense to present them here first.

    These 17 safeguards are organized
from the most important to the least important.

And they keep their letters from the comprehensive list
in How to Die: Safeguards for Life-Ending Decisions.


SAFEGUARD B  Requests for Death from the Patient

SAFEGUARD A  Advance Directive for Medical Care

SAFEGUARD J  Informed Consent from the Patient

SAFEGUARD C  Psychological Consultant
                               Evaluates the Patient's Ability to Make Medical Decisions

SAFEGUARD D  Physician's Statement of Condition and Prognosis

SAFEGUARD E  Independent Physician Reviews the Condition and Prognosis

SAFEGUARD F  Certification of Terminal Illness or Incurable Condition

SAFEGUARD G  Unbearable Suffering

SAFEGUARD H  Unbearable Psychological Suffering

SAFEGUARD V  Opportunities for the Patient to Rescind or Postpone
                               the Life-Ending Decision


SAFEGUARD K  Requests for Death from the Proxies

SAFEGUARD N  Statements from Family Members
                                Affirming or Questioning Choosing Death


SAFEGUARD U  Waiting Periods For Reflection

SAFEGUARD M  Statements from Hospital or Hospice Staff Members

SAFEGUARD X  Complete Recording and Sharing
                                of All Material Facts and Opinions


SAFEGUARD AA   Information about Palliative Care
                                    and other Alternatives to Death


SAFEGUARD DD  The Patient Must be an Adult Resident of the State
(This residency requirement is implicit in the requirement
that the patient
be covered by Quebec's health-insurance program.)


    By this count, there are 17 safeguards in Quebec's right-to-die law.
This law gives official, legal authorization
to three medical methods of managing dying:

(1) The smallest number of safeguards apply to
ending medical treatments (Section  5).

(2) The next larger number of safeguards apply to
continuous palliative sedation (Section 24),

(3) And the most safeguards are applied to
medical aid in dying (Sections 26-32).


    Where these 17 safeguards appear in the text of Quebec's right-to-die law,
they are linked to the complete explanation on the Internet.
These links and these explanations are NOT parts of Quebec's law.

    Additional constructive comments appear at the end of this law.



© Éditeur officiel du Québec 
Updated to 1 April 2016 
This document has official status.


chapter S-32.0001

AN ACT RESPECTING END-OF-LIFE CARE

TITLE I 
PURPOSE OF ACT

1. The purpose of this Act is to ensure that end-of-life patients
are provided care that is respectful of their dignity and their autonomy.
The Act establishes the rights of such patients
as well as the organization of and a framework for end-of-life care
so that everyone may have access, throughout the continuum of care,
to quality care that is appropriate to their needs,
including prevention and relief of suffering.

In addition, the Act recognizes the primacy
of freely and clearly expressed wishes with respect to care,
in particular by establishing an advance medical directives regime.

2014, c. 2, s. 1.

TITLE II 
END-OF-LIFE CARE

CHAPTER I 
GENERAL PROVISIONS

2. The provision of end-of-life care is to be guided by the following principles:

 (1) respect for end-of-life patients and recognition of their rights and freedoms
must inspire every act performed in their regard;

 (2) end-of-life patients must be treated, at all times,
with understanding, compassion, courtesy and fairness,
and with respect for their dignity, autonomy, needs and safety; and

 (3) the healthcare team providing care to end-of-life patients
must establish and maintain open and transparent communication with them.

2014, c. 2, s. 2.

3. For the purposes of this Act,

 (1) institution means any institution governed by the Act
respecting health services and social services (chapter S-4.2)
that operates a local community service centre,
a hospital centre or a residential and long-term care centre,
as well as the Cree Board of Health and Social Services of James Bay
established under the Act respecting health services and social services
for Cree Native persons (chapter S-5);

 (2) palliative care hospice means a community organization
that holds an accreditation granted by the Minister
under the second paragraph of section 457 of the Act
respecting health services and social services
and has entered into an agreement with an institution under section 108.3 of that Act
in order to secure all or some of the care required by its users;

 (3) end-of-life care means palliative care provided to end-of-life patients
and medical aid in dying;

 (4) palliative care means the total and active care
delivered by an interdisciplinary team
to patients suffering from a disease with reserved prognosis,
in order to relieve their suffering, without delaying or hastening death,
maintain the best quality of life possible
and provide them and their close relations the support they need;

 (5) continuous palliative sedation means care that is offered as part of palliative care
and consists in administering medications or substances to an end-of-life patient
to relieve their suffering by rendering them unconscious without interruption until death ensues; and

 (6) medical aid in dying means care consisting in the administration
by a physician of medications or substances to an end-of-life patient,
at the patient's request, in order to relieve their suffering by hastening death.

2014, c. 2, s. 3.

CHAPTER II 
RIGHTS WITH RESPECT TO END-OF-LIFE CARE

4. Every person whose condition requires it has the right to receive end-of-life care,
subject to the specific requirements established by this Act.

Such care is provided to the person
in a facility maintained by an institution, in a palliative care hospice or at home.

This section applies within the framework of the legislative and regulatory provisions
relating to the organizational and operational structure of institutions
and the policy directions, policies and approaches of palliative care hospices
and within the limits of the human, material and financial resources at their disposal.
It complements the provisions of the Act respecting health services and social services (chapter S-4.2)
and of the Act respecting health services and social services for Cree Native persons (chapter S-5)
that relate to the rights of users and beneficiaries.

2014, c. 2, s. 4.

5. Except as otherwise provided by law, a person of full age
who is capable of giving consent to care may, at any time,
refuse to receive life-sustaining care or withdraw consent to such care.

To the extent provided by the Civil Code, a minor of 14 years of age or over,
and in the case of a minor or a person of full age who is incapable of giving consent,
the person who may give consent to care on their behalf may also make such a decision.

The refusal of care or withdrawal of consent to care may be expressed by any means.

The physician must make sure that such a decision is made freely
and provide the person with all information needed to make an informed decision,
in particular information about other therapeutic possibilities, including palliative care.

2014, c. 2, s. 5.

6. A person may not be denied end-of-life care
for previously having refused to receive certain care
or having withdrawn consent to certain care.

2014, c. 2, s. 6.

CHAPTER III 
ORGANIZATION OF END-OF-LIFE CARE

DIVISION I 
SPECIAL RULES APPLICABLE TO PROVIDERS OF END-OF-LIFE CARE

§ 1. —  Institutions

7. Every institution must offer end-of-life care
and ensure that it is provided to the persons requiring it
in continuity and complementarity with any other care that is or has been provided to them.

For this purpose, an institution must, among other things, establish measures to promote
a multiple-discipline approach by health and social services professionals
and the collaboration of the various other resources concerned who provide services to its users.

2014, c. 2, s. 7.

8. Every institution must adopt a policy with respect to end-of-life care.
The policy must be consistent with ministerial policy directions
and be made known to the personnel of the institution,
to the health and social services professionals who practise in the institution,
and to end-of-life patients and their close relations.

The executive director of the institution must report annually
to the board of directors on the carrying out of the policy.
The report must include the number of end-of-life patients who received palliative care,
the number of times continuous palliative sedation was administered,
the number of requests for medical aid in dying,
the number of times such aid was administered
as well as the number of times medical aid in dying was not administered,
including the reasons it was not administered.

The report must also state, where applicable, the number of times
continuous palliative sedation and medical aid in dying were administered
at the patient's home or in the premises of a palliative care hospice
by a physician as a physician practising in a centre operated by the institution.

The report is to be published on the website of the institution
and sent, not later than 30 June each year,
to the Commission sur les soins de fin de vie established under section 38.
The institution must include a summary of the report
in a separate section of its annual management report.

2014, c. 2, s. 8.

9. Every institution must include a clinical program for end-of-life care in its organization plan.
In the case of an institution that operates a local community service centre,
the plan must also include the provision of end-of-life care at the patient's home.

The organization plan must be consistent with ministerial policy directions.

The clinical program for end-of-life care is to be sent to the Commission sur les soins de fin de vie.

2014, c. 2, s. 9.

10. The code of ethics adopted by an institution
under section 233 of the Act respecting health services and social services (chapter S-4.2)
must have due respect for the rights of end-of-life patients.

2014, c. 2, s. 10.

11. When an end-of-life patient requests in-home palliative care from an institution,
but the person's condition or environment is such that proper care could not be provided at home,
the institution must offer to admit the person to its facilities
or direct them to another institution or to a palliative care hospice that can meet their needs.

2014, c. 2, s. 11.

12. An institution must offer every patient receiving end-of-life care
a private room for the final few days preceding the patient's death.

2014, c. 2, s. 12.

§ 2. —  Palliative care hospices

13. Palliative care hospices determine the end-of-life care provided in their premises.

Every palliative care hospice must inform persons
of the end-of-life care it offers before admitting them.

2014, c. 2, s. 13.

14. A palliative care hospice and an institution must specify in their agreement
under section 108.3 of the Act respecting health services and social services (chapter S-4.2)
the nature of the services the institution is to provide in the premises of the hospice
and the monitoring mechanisms that will allow the institution,
or one of its boards, councils or committees determined in the agreement,
to ensure that quality care is provided in the hospice.

On the request of the institution, the palliative care hospice must communicate
any information required for the carrying out of the agreement.
The manner in which such information is to be communicated is specified in the agreement.

2014, c. 2, s. 14.

15. Every palliative care hospice must adopt a code of ethics
with respect to the rights of end-of-life patients
and adopt a policy with respect to end-of-life care.

These documents must be made known to the personnel of the palliative care hospice,
to the health and social services professionals who practise in the hospice,
and to end-of-life patients and their close relations.

2014, c. 2, s. 15.

§ 3. —  Private health facilities

16. End-of-life care may be provided at the patient's home
by physicians practising in a private health facility
within the meaning of section 95 of the Act
respecting health services and social services (chapter S-4.2)
and, within their scope of practice, by nurses practising in such a facility.

2014, c. 2, s. 16.

DIVISION II 
SPECIAL FUNCTIONS OF HEALTH AND SOCIAL SERVICES AGENCIES

17. Every health and social services agency must,
after consultation with the institutions and palliative care hospices in its territory,
determine the general rules governing access to the end-of-life care
provided by those institutions and hospices.

2014, c. 2, s. 17.

18. Every agency must inform the population living in its territory
of the end-of-life care services available and the manner of accessing them,
as well as the rights and options of end-of-life patients.

This information must be available on the websites of the agencies.

2014, c. 2, s. 18.

DIVISION III 
SPECIAL FUNCTIONS AND POWERS OF THE MINISTER

19. The Minister determines the policy directions that are to guide institutions
and agencies when organizing end-of-life care,
including those which institutions must take into account
when formulating their end-of-life care policy.

2014, c. 2, s. 19.

20. The Minister may require of institutions,
palliative care hospices and agencies that they supply,
in the manner and within the time specified,
statements, statistical data, reports and other information
required for the performance of the functions vested in the Minister under this Act,
provided it is not possible to link that information
to any specific patient having received end-of-life care
or to any specific health or social services professional having provided the care.

2014, c. 2, s. 20.

21. In order to ascertain compliance with this Title,
a person authorized in writing by the Minister to carry out an inspection may,
at any reasonable time, with due respect for the specific character of the premises
and the needs of the persons receiving end-of-life care,
enter any premises operated by an institution or a palliative care hospice.

The person may, during an inspection,

 (1) examine and make a copy of any document
relating to the end-of-life care offered in those premises; and

 (2) demand any information relating to the carrying out of this Title
as well as the production of any related document.

Any person having custody, possession or control of such documents
must make them available on request to the person conducting the inspection.

A person conducting an inspection must, if so required, produce a certificate of capacity.

Any person who hinders a person in the conduct of an inspection,
refuses to provide any information or document the latter is entitled to require or examine,
or conceals or destroys any document or other object relevant to an inspection
is guilty of an offence and is liable to a fine of $2,500 to $25,000
in the case of a natural person and to a fine of $7,500 to $75,000 in any other case.

2014, c. 2, s. 21.

22. The Minister may delegate the powers provided for in section 21
to a health and social services agency.

The agency informs the Minister of the designation of an inspector
and of the results of the inspection.

2014, c. 2, s. 22.

23. A person authorized in writing by the Minister
or, where applicable, by an agency to carry out an inspection
may not be prosecuted for an omission or an act done in good faith
in the performance of their duties.

2014, c. 2, s. 23.

CHAPTER IV 
SPECIAL REQUIREMENTS FOR CERTAIN END-OF-LIFE CARE

DIVISION I 
CONTINUOUS PALLIATIVE SEDATION

24. Before giving consent to continuous palliative sedation, an end-of-life patient
or, where applicable, the person who may give consent to care on behalf of the patient
must among other things be informed of the prognosis for the illness,
the irreversible nature of the sedation and the anticipated duration of the sedation.

In addition, the physician must make sure that the request is being made freely,
in particular by ascertaining that it is not being made as a result of external pressure.

Consent to continuous palliative sedation must be given in writing
on the form prescribed by the Minister and be filed in the patient's record.

2014, c. 2, s. 24.

25. If the patient giving consent to continuous palliative sedation
cannot date and sign the form referred to in section 24
because the patient cannot write or is physically incapable of doing so,
a third person may do so in the patient's presence.
The third person may not be a member of the team responsible for caring for the patient,
a minor or a person of full age incapable of giving consent.

2014, c. 2, s. 25.

DIVISION II 
MEDICAL AID IN DYING

26. Only a patient who meets all of the following criteria may obtain medical aid in dying:

 (1) be an insured person within the meaning of the Health Insurance Act (chapter A-29);


 (3) be at the end of life;

 (4) suffer from a serious and incurable illness;

 (5) be in an advanced state of irreversible decline in capability; and

 (6) experience constant and unbearable physical or psychological suffering
which cannot be relieved in a manner the patient deems tolerable.

The patient must request medical aid in dying themselves,
in a free and informed manner, by means of the form prescribed by the Minister.
The form must be dated and signed by the patient.

The form must be signed in the presence of
and countersigned by a health or social services professional;
if the professional is not the attending physician,
the signed form is to be given by the professional to the attending physician.

2014, c. 2, s. 26.

27. If the patient requesting medical aid in dying
cannot date and sign the form referred to in section 26
because the patient cannot write or is physically incapable of doing so,
a third person may do so in the patient's presence.
The third person may not be a member of the team responsible for caring for the patient,
a minor or a person of full age incapable of giving consent.

2014, c. 2, s. 27.

28. A patient may, at any time and by any means,
withdraw their request for medical aid in dying.

A patient may also, at any time and by any means,
request that the administration of medical aid in dying be put off.

2014, c. 2, s. 28.

29. Before administering medical aid in dying, the physician must

 (1) be of the opinion that the patient meets all the criteria of section 26,
after, among other things,

(a)  making sure that the request is being made freely,
in particular by ascertaining that it is not being made as a result of external pressure;

(b)  making sure that the request is an informed one,
in particular by informing the patient of the prognosis for the illness
and of other therapeutic possibilities and their consequences;

(c)  verifying the persistence of suffering
and that the wish to obtain medical aid in dying remains unchanged,
by talking with the patient at reasonably spaced intervals
given the progress of the patient's condition;

(d)  discussing the patient's request with any members of the care team
who are in regular contact with the patient; and

(e)  discussing the patient's request with the patient's close relations,
if the patient so wishes;

 (2) make sure that the patient has had the opportunity
to discuss the request with the persons they wished to contact; and

 (3) obtain the opinion of a second physician
confirming that the criteria set out in section 26 have been met.

The physician consulted must be independent
of both the patient requesting medical aid in dying
and the physician seeking the second medical opinion.
The physician consulted must consult the patient's record,
examine the patient and provide the opinion in writing.

2014, c. 2, s. 29.

30. If a physician determines, subsequent to the application of section 29,
that medical aid in dying may be administered to a patient requesting it,
the physician must administer such aid personally
and take care of and stay with the patient until death ensues.

If the physician determines that medical aid in dying cannot be administered,
the physician must inform the patient of the reasons for that decision.

2014, c. 2, s. 30.

31. A physician practising in a centre operated by an institution
who refuses a request for medical aid in dying for a reason not based on section 29
must, as soon as possible, notify the executive director of the institution
or any other person designated by the executive director
and forward the request form given to the physician, if that is the case,
to the executive director or designated person.
The executive director of the institution or designated person
must then take the necessary steps to find, as soon as possible, another physician
willing to deal with the request in accordance with section 29.

If the physician who receives the request practises in a private health facility
and does not provide medical aid in dying,
the physician must, as soon as possible, notify
the executive director of the local authority referred to in section 99.4
of the Act respecting health services and social services (chapter S-4.2)
that serves the territory in which the patient making the request resides,
or notify the person designated by the executive director.
The physician forwards the request form received, if that is the case,
to the executive director or designated person
and the steps mentioned in the first paragraph must be taken.

If no local authority serves the territory in which the patient resides,
the notice referred to in the second paragraph is forwarded
to the executive director of the institution operating a local community service centre
in the territory or the person designated by the executive director.

2014, c. 2, s. 31.

32. All information and documents in connection with a request for medical aid in dying,
regardless of whether the physician administers it or not,
including the form used to request such aid, the reasons for the physician's decision
and, where applicable, the opinion of the physician consulted,
must be recorded or filed in the patient's record.

A decision to withdraw a request for medical aid in dying
or to put off the administration of such aid must also be recorded in the patient's record.

2014, c. 2, s. 32.

DIVISION III 
SPECIAL FUNCTIONS OF THE COUNCIL OF PHYSICIANS, DENTISTS AND PHARMACISTS

33. The council of physicians, dentists and pharmacists established for an institution
must, in collaboration with the council of nurses of the institution,
adopt clinical protocols for continuous palliative sedation and medical aid in dying.
The protocols must comply with the clinical standards
developed by the professional orders concerned.

2014, c. 2, s. 33.

34. A physician who provides continuous palliative sedation or medical aid in dying
as a physician practising in a centre operated by an institution
must, within 10 days following its administration,
inform the council of physicians, dentists and pharmacists
of which the physician is a member,
whether it is administered in the facilities of an institution,
in the premises of a palliative care hospice or at the patient's home.

The council of physicians, dentists and pharmacists or its competent committee
assesses the quality of the care provided,
particularly with regard to applicable clinical protocols.

2014, c. 2, s. 34.

35. If no council of physicians, dentists and pharmacists is established for the institution,
the head of medical services or the physician responsible for medical care in the institution,
as applicable, assumes the functions assigned to the council under this division,
and the physician informs that person in accordance with the first paragraph of section 34.

2014, c. 2, s. 35.

DIVISION IV 
SPECIAL FUNCTIONS OF THE COLLÈGE DES MÉDECINS DU QUÉBEC

36. Physicians practising in a private health facility
that provides continuous palliative sedation or medical aid in dying
at the patient's home or in the premises of a palliative care hospice
must, within 10 days following its administration,
inform the Collège des médecins du Québec and send to it,
under the conditions and in the manner prescribed by the Collège,
the information it determines.

The Collège or its competent committee assesses the quality of the care provided,
particularly with regard to applicable clinical standards.

2014, c. 2, s. 36.

37. The Collège des médecins du Québec must prepare a yearly report
on the end-of-life care provided by physicians practising in private health facilities.

The report must state the number of times
continuous palliative sedation and medical aid in dying were administered
by such physicians at the patient's home or in the premises of a palliative care hospice.
The information must be grouped by local health and social services network territory
and health and social services agency territory.

The report is to be published on the website of the Collège and sent,
not later than 30 June each year, to the Commission sur les soins de fin de vie.

2014, c. 2, s. 37.

CHAPTER V 
COMMISSION SUR LES SOINS DE FIN DE VIE

DIVISION I 
ESTABLISHMENT AND FUNCTIONING OF THE COMMISSION

38. A commission on end-of-life care (“the Commission”) is established
under the name “Commission sur les soins de fin de vie”.

2014, c. 2, s. 38.

39. The Commission is composed of 11 members, appointed by the Government as follows:

 (1) five members are to be health or social services professionals, including

(a)  two members appointed after consultation with the Collège des médecins du Québec;

(b)  one member appointed after consultation with the Ordre des infirmières et infirmiers du Québec;

(c)  one member appointed after consultation with the Ordre des pharmaciens du Québec; and

(d)  one member appointed after consultation with the Ordre professionnel
des travailleurs sociaux et des thérapeutes conjugaux et familiaux du Québec;

 (2) two members are to be jurists, appointed after consultation
with the Barreau du Québec and the Chambre des notaires du Québec;

 (3) two members are to be users of institutions,
appointed after consultation with bodies representing the users' committees of institutions;

 (4) one member is to be from the ethics community,
appointed after consultation with university-level educational institutions; and

 (5) one member is to be appointed after consultation with bodies representing institutions.

The Government must ensure that at least one member
appointed under subparagraph 1 of the first paragraph is from the palliative care community.

The members of the Commission are appointed for a term of not more than five years.
Their terms of office may be renewed consecutively only once.
At the expiry of their terms, members remain in office until they are replaced or reappointed.

The Government designates,
from among the members of the Commission, a chair and vice-chair;
the vice-chair shall chair the Commission when the chair is absent or unable to act.

The Government fixes the allowances and indemnities of the members of the Commission.

2014, c. 2, s. 39.

40. The Commission may make by-laws concerning its internal management.

2014, c. 2, s. 40.

41. The quorum at meetings of the Commission is seven members,
including the chair or the vice-chair.

Subject to the second paragraph of section 47,
the decisions of the Commission are made by a majority vote of the members present.
In the case of a tie vote, the person presiding at the meeting has a casting vote.

2014, c. 2, s. 41.

DIVISION II 
MANDATE OF THE COMMISSION

42. The mandate of the Commission is to examine any matter relating to end-of-life care.
For this purpose, it must, among other things,

 (1) advise the Minister on any matter put before it by the Minister;

 (2) evaluate the implementation of legislation with regard to end-of-life care;

 (3) refer to the Minister any matter relating to end-of-life care
that needs the attention of or action by the Government,
and submit its recommendations to the Minister;

 (4) submit a report to the Minister, every five years,
on the status of end-of-life care in Québec; and

 (5) carry out any other mandate given to it by the Minister.

The Commission also has the mandate
of overseeing the application of the specific requirements
relating to medical aid in dying in compliance with this division.

The Commission is to submit an annual activity report,
not later than 30 September each year, to the Minister.

2014, c. 2, s. 42.

43. The Minister tables the reports produced by the Commission
in the National Assembly within 30 days of receiving them
or, if the Assembly is not sitting, within 30 days of resumption.
The competent committee of the National Assembly examines the reports.

2014, c. 2, s. 43.

44. In exercising its functions under the first paragraph of section 42,
the Commission may, as an exception, take such measures as

 (1) soliciting the opinion of individuals or groups on any end-of-life care issue;

 (2) conducting or commissioning studies and research it deems necessary; and

 (3) calling on outside experts to report to it on one or more specific points.

2014, c. 2, s. 44.

45. The Commission may require of institutions, palliative care hospices,
physicians practising in a private health facility and agencies that they supply,
in the manner and within the time specified, the statements, statistical data,
reports and other information it needs for the performance of its functions
under the first paragraph of section 42,
provided it is not possible to link that information to any specific patient
having received end-of-life care
or to any specific health or social services professional having provided the care.

2014, c. 2, s. 45.

46. A physician who administers medical aid in dying
must give notice to the Commission within the next 10 days and send the Commission,
in the manner determined by government regulation, the information prescribed by regulation.
This information is confidential and may not be disclosed to any other person,
except to the extent that is necessary for the purposes of this section and section 47.

Any person who notes that a physician has contravened this section
must bring the breach to the attention of the Collège des médecins du Québec
so that it can take appropriate measures.

2014, c. 2, s. 46.

47. On receiving the notice from the physician,
the Commission assesses compliance with section 29
in accordance with the procedure prescribed by government regulation.

On completion of the assessment, if two thirds or more of the members present
are of the opinion that section 29 was not complied with,
the Commission sends a summary of its conclusions to the Collège des médecins du Québec
and, when the physician provided the medical aid in dying
as a physician practising in a centre operated by an institution,
to the institution concerned so that they can take appropriate measures.

2014, c. 2, s. 47.

CHAPTER VI 
MISCELLANEOUS PROVISIONS

48. Complaints regarding end-of-life care
made by any person to a local or regional service quality complaints commissioner,
in accordance with the rules prescribed
in Divisions I to III of Chapter III of Title II of Part I of the Act
respecting health services and social services (chapter S-4.2),
must be given priority treatment.
The same applies to complaints regarding end-of-life care
made to the syndic of the Collège des médecins du Québec.

2014, c. 2, s. 48.

49. The decision of a patient or, where applicable,
of the person who may give consent to care on the patient's behalf
to refuse certain life-sustaining care or withdraw consent to such care
or to request continuous palliative sedation or medical aid in dying
may not be invoked as a reason to refuse to pay a benefit
or any other sum due under a contract.

2014, c. 2, s. 49.

50. A physician may refuse to administer medical aid in dying
because of personal convictions,
and a health professional may refuse to take part in administering it for the same reason.

In such a case, the physician or health professional
must nevertheless ensure that continuity of care is provided to the patient,
in accordance with their code of ethics and the patient's wishes.

In addition, the physician must comply with the procedure established in section 31.

2014, c. 2, s. 50.

TITLE III 
ADVANCE MEDICAL DIRECTIVES

CHAPTER I 
GENERAL PROVISIONS

51. A person of full age who is capable of giving consent to care may,
by means of advance medical directives, specify whether or not they consent to care
that may be required by their state of health,
in the event they become incapable of giving consent.
However, in such directives the person may not request medical aid in dying.

2014, c. 2, s. 51.

52. Advance medical directives are given by notarial act en minute
or in the presence of witnesses on the form prescribed by the Minister.

not in force
At the request of their author, advance medical directives are to be recorded
in the advance medical directives register established under section 63.


2014, c. 2, s. 52.

53. When advance medical directives are given in the presence of witnesses,
the form must be completed by the person concerned.

The person then declares, in the presence of two witnesses,
that the form contains the person's advance medical directives,
without having to disclose the contents.
The person dates and signs the form
or, if this is already done, recognizes the signature as their own.
The form is then signed by the witnesses in the person's presence.

If the person cannot complete the form
because the person cannot write or is physically incapable of doing so,
it may be completed by a third person in accordance with the person's instructions.
The third person signs and dates the form in the person's presence.

Persons of full age incapable of giving consent and minors
cannot act as a third person or a witness for the purposes of this section.

2014, c. 2, s. 53.

54. Advance medical directives may be revoked at any time
by the person concerned by means of the form prescribed by the Minister.

Such directives may only be changed by writing new ones
by one of the methods specified in the first paragraph of section 52.
The new directives replace any previous ones.

Despite the first and second paragraphs, in emergency cases,
if a person capable of giving consent to care verbally expresses wishes
different from those in their advance medical directives,
this entails the revocation of the directives.

2014, c. 2, s. 54.

55. When advance medical directives are given to a health professional,
that professional files them in the record of the person concerned if this has not yet been done.
If the directives are given to the health professional by the person concerned
and the person is capable of giving consent to care,
the health professional must first inquire whether they still correspond to the person's wishes.

2014, c. 2, s. 55.

56. A physician who notes a significant change
in the state of health of a person capable of giving consent to care
must, if advance medical directives have been filed in the person's record,
inquire whether the directives still correspond to the person's wishes.

2014, c. 2, s. 56.

not in force
57. A physician who notes that a person is incapable of giving consent to care
consults the advance medical directives register.
If the register contains advance medical directives for the person,
the physician files them in the person's record.

2014, c. 2, s. 57.


58. When a person is incapable of giving consent to care,
clearly expressed instructions relating to care
that are recorded in the advance medical directives register
or filed in the person's record carry,
for all health professionals having access to the register or record,
the same weight as wishes expressed by a person capable of giving consent to care.

2014, c. 2, s. 58.
This section is not in force
to the extent that it concerns the advance medical directives register.


59. The author of advance medical directives
is presumed to have been in the possession of the information needed
to make an informed decision at the time of signing the directives.

2014, c. 2, s. 59.

60. If a person incapable of giving consent to care categorically refuses care
which they had previously consented to in advance medical directives,
article 16 of the Civil Code, requiring the authorization of the court, applies.

2014, c. 2, s. 60.

61. The court may, on the application of the mandatary, tutor, curator of
or any person showing a special interest in the author of advance medical directives,
order that the instructions relating to care expressed in those directives be carried out.

The court may also, on the application of such a person, a physician or an institution,
invalidate advance medical directives, in full or in part,
if it has reasonable grounds to believe that the author of the directives
was not capable of consenting to the care at the time of signing the directives
or that the directives do not correspond to the author's wishes in the present situation.

The court may, in addition,
make any other order it considers appropriate in the circumstances.

2014, c. 2, s. 61.

62. Instructions relating to care expressed in a protection mandate
do not constitute advance medical directives within the meaning of this Act
and remain subject to articles 2166 and following of the Civil Code.

In case of inconsistency between those instructions for care
and the instructions contained in advance medical directives, the latter prevail.

2014, c. 2, s. 62; I.N. 2016-01-01 (NCCP).

CHAPTER II 
ADVANCE MEDICAL DIRECTIVES REGISTER

63. The Minister establishes and maintains an advance medical directives register.

The Minister may manage the register or entrust its management to a body
that is subject to the Act respecting Access to documents held by public bodies
and the Protection of personal information (chapter A-2.1).
In the latter case, the Minister enters into a written agreement with the manager.

2014, c. 2, s. 63.

64. The Minister prescribes, by regulation,
how the register is to be accessed and operated,
including who may record advance medical directives in the register and who may consult it.

2014, c. 2, s. 64.

TITLE IV 
AMENDING, TRANSITIONAL AND FINAL PROVISIONS

CHAPTER I 
AMENDING PROVISIONS

CIVIL CODE OF QUÉBEC

65. (Amendment integrated into the Civil Code, a. 11).

2014, c. 2, s. 65.

66. (Amendment integrated into the Civil Code, a. 12).

2014, c. 2, s. 66.

67. (Amendment integrated into the Civil Code, a. 15).

2014, c. 2, s. 67.

CODE OF CIVIL PROCEDURE

68. (Amendment integrated into c. C-25, a. 776).

2014, c. 2, s. 68.

MEDICAL ACT

69. (Amendment integrated into c. M-9, s. 31).

2014, c. 2, s. 69.

PHARMACY ACT

70. (Amendment integrated into c. P-10, s. 17).

2014, c. 2, s. 70.

ACT RESPECTING HEALTH SERVICES AND SOCIAL SERVICES

71. (Amendment integrated into c. S-4.2, s. 19).

2014, c. 2, s. 71.

CHAPTER II 
TRANSITIONAL AND FINAL PROVISIONS

72. Despite section 7, an institution which, on 10 December 2015,
operates a general and specialized hospital centre and,
within the range of care that may be offered pursuant to the mission of such a centre,
only offers palliative care may continue to offer that care exclusively.

Such an institution must inform persons of the end-of-life care it offers before admitting them.

2014, c. 2, s. 72.

73. Until 10 December 2017, executive directors of institutions
must report every six months to their board of directors
as described in the second paragraph of section 8.
The institutions are to forward the report to the Commission sur les soins de fin de vie
as soon as possible and publish it on their website.

Until that date, the Collège des médecins du Québec
is also to send the Commission the report required under section 37 every six months.

2014, c. 2, s. 73.

74. Institutions and palliative care hospices have until 10 December 2016
to amend the agreement they have entered into under section 108.3
of the Act respecting health services and social services (chapter S-4.2)
in order to bring it into conformity with section 14.

2014, c. 2, s. 74.

75. Despite subparagraph 4 of the first paragraph of section 42,
the Commission sur les soins de fin de vie must send its first report
on the status of end-of-life care not later than 10 December 2018.

2014, c. 2, s. 75.

76. The Minister must, not later than 10 December 2019,
report to the Government on the implementation of this Act,
and subsequently every five years, report to the Government on the carrying out of this Act.

Such report is tabled by the Minister in the National Assembly within the next 30 days
or, if the Assembly is not sitting, within 30 days of resumption.
The report is examined by the competent committee of the National Assembly.

2014, c. 2, s. 76.

77. The Minister of Health and Social Services is responsible for the administration of this Act.

2014, c. 2, s. 77.

78. (Omitted).

2014, c. 2, s. 78.




COMMENTS ON QUEBEC'S RIGHT-TO-DIE LAW
by James Leonard Park


OUTLINE:

1.  THE NUMBER OF DEATHS INCLUDED IN THE LEGISLATION

2.  QUEBEC'S RIGHT-TO-DIE LAW
             DOES NOT CONFLICT WITH CANADIAN NATIONAL LAWS

3.  ADDITIONAL DEFINITIONS NEEDED

4.  ADDITIONAL METHODS OF CHOOSING DEATH COULD BE INCLUDED

5.  ALL HEALTH-CARE INSTITUTIONS MUST PROVIDE END-OF-LIFE CARE

6.  ALL THE EMBEDDED SAFEGUARDS COULD BE GATHERED INTO ONE PLACE

~~~~~~~~~~~


1.  THE NUMBER OF DEATHS INCLUDED IN THE LEGISLATION

    Having analyzed several other laws and proposed laws concerning the right-to-die,
in my opinion, Quebec's Act Respecting End-of-Life 'Care
has the potential to cover more deaths than any other right-to-die legislation.
This is because it mentions refusing medical treatment and terminal sedation
as well as "medical aid in dying".

    According to estimates explained here,
withdrawing or withholding medical treatments and life-supports
is the method of managing dying in 10-15% of all deaths
in countries with modern medicine.

    Also terminal sedation is another medical method of managing dying
used in 5-10% of all deaths.

    These numbers are found in countries
that also permit the use of gentle poison as a method of choosing death.
The doctor providing lethal chemicals to cause death
accounts for about 2% of all deaths in these countries.

    Adding these medical methods of managing dying together,
the totals come to 17-27% of all deaths.

    This means that Quebec's law covers about 10 times as many deaths
as legislation that only authorizes gentle poison provided by doctors.

    If Quebec's law (or other laws adapted from it) expands to include
all 5 methods of managing dying discussed in Comment 4 below,
then over 50% of all deaths in that jurisdiction will be covered.




2.  QUEBEC'S RIGHT-TO-DIE LAW
            DOES NOT CONFLICT WITH CANADIAN NATIONAL LAWS

    On February 6, 2015, the Supreme Court of Canada
lifted the ban on 'assisted suicide' for all of Canada.
With a 16-month delay to allow the Parliament of Canada
to enact new federal criminal laws with respect to the right-to-die,
the old laws and court rulings that might have prevented
reasonable end-of-life medical decisions were struck down.

    When Bill 52 was first passed in Quebec (in 2014),
it probably did contradict Canadian federal criminal law
especially Quebec's provision for "medical aid in dying".
But now the Supreme Court of Canada
has lifted the overly-broad ban on 'assisting suicide'.
And the Supreme Court of Canada
has explicitly permitted Quebec's law to go forward.

    Canadian federal law covers all criminal matters.
(The organization of health care is left to the provinces.)
And until this ruling by the Supreme Court of Canada,
the federal Criminal Code prohibited and punished
committing euthanasia or assisting a suicide.

    Now "medical aid in dying" will no longer be against federal criminal law.
And the other mentioned methods of choosing death are still legal:

    Refusing further medical care intended to postpone death
is a legal and ethical option wherever modern medical care prevails.

    And terminal sedation remains a medical option:
The doctor can order drugs to keep the patient unconscious until death comes.

    Both of these methods of managing the process of dying
are well-recognized in most countries with modern medical care.
Only occasionally is there a legal challenge to either of these methods of dying.

    All doctors and patients will be assured by the words of Quebec's right-to-die law
that (under reasonable standards of medical care)
it is legal to withdraw or withhold any and all medical treatments and life-supports.
Also it is legal for a physician to order sufficient drugs
to keep the patient completely and permanently unconscious until death occurs.

    There are many other meaningful and useful provisions of Quebec's law
which were never in conflict with Canadian national law.
For example, the Commission on End-of-Life Care
and the Advance Directives Registry
are major advances for terminal medical care. 
(As noted in the text above, the Advance Directive Register
is not yet in effect.)

  



3.  ADDITIONAL DEFINITIONS NEEDED


    Refusing any and all further medical treatments and life-supports
is probably clear enough all by itself.
But it would do no harm to define and describe these behaviors
at the beginning of the law.
For example, when is providing food and water a medical treatment
that may therefore be refused under this law?

    The expression "continuous palliative sedation"
will probably be clear to all lawyers and doctors.
But members of the general public who are not familiar with this concept
would benefit from having it spelled out:
The doctor orders that the patient be kept
completely and permanently unconscious by means of sedative drugs
until natural death occurs.
Keeping the patient asleep until death
is not the same as giving chemicals that cause immediate death.

    "Medical aid in dying" is defined for the first time in this version of the law:
Chapter I, Section 3, item (6):
"Medical aid in dying" means care consisting in the administration
by a physician of medications or substances to the end-of-life patient,
at the patient's request, in order to relieve suffering and hasten death.

 


4.  ADDITIONAL METHODS OF CHOOSING DEATH COULD BE INCLUDED


    More than most other legislation concerning the right-to-die,
this law does take into account the ways modern medical care is now provided.

    Three out of five medical methods of managing dying are mentioned.
It would do no harm to name the other two,
which are very common in the modern hospital:

    1. Increasing pain-medication means
changing the dose of drugs already in use with the knowledge
that the same drugs being used to relieve pain and suffering
will probably also shorten the process of dying. 
The laws of a few other countries (and states of the USA)
do recognize this modern medical practice.
And when the amount of drugs given are within standard terminal care,
no crime has been committed.

    2. Medical dehydration means giving up all food and water
with the knowledge that death will inevitably follow within a few days.
This change in medical treatment is usually ordered
when the patient is also being removed from
all other forms of curative medical treatment and life-support.
And since section 5 of this law allows all forms of medical care to be refused,
this could be interpreted to include
providing food and water by artificial means.

    However, as said about increasing pain-medication,
it does no harm to put into unambiguous words
the practice of allowing doctors to order
that food and water be discontinued for this dying patient.

    In short, five medical methods of managing dying
could be named and described in any revised end-of-life law
(or any other right-to-die legislation adapted from Quebec's law):

1. increasing pain-medication with the knowledge
that the process of dying might be shortened as a side-effect.

2. terminal sedation
keeping the patient permanently asleep until death comes.

3. ending all curative medical treatments and life-supports.

4. withdrawing or withholding food and water
with the certain knowledge that death will result.

5. gentle poison provided by a doctor,
which could include lethal injections or death pills.




5.  ALL HEALTH-CARE INSTITUTIONS
            MUST PROVIDE END-OF-LIFE CARE


    Perhaps most casual readers of this law will read right thru these provisions
without noticing that this is a major change in health-care policy. 
End-of-life care MUST include "palliative care" and "medical aid in dying".
No institutions may exempt themselves from these services
by saying that it is against their religion or some other consideration.
(Section 7 and following)

    However, later in this law, individuals physicians are offered
the freedom to avoid involvement in life-ending decisions.

   If Quebec's right-to-die law is revised to include
increasing pain-medication and medical dehydration,
these would also be approved methods of choosing death
that must be available in any health-care institution.

    This pattern could also be followed by any other province, state, or country
that adapts Quebec's right-to-die law for its own jurisdiction:
All health-care organizations could be required to provide
all of the named medical methods of managing dying.




6.  ALL THE EMBEDDED SAFEGUARDS
            COULD BE GATHERED INTO ONE PLACE


    Opponents of the right-to-die often argue
that there are not enough safeguards to protect patients
in any legislation that allows life-ending decisions.

    Quebec's "An Act Concerning End-of-Life Care"
contains at least 17 safeguards,
which are organized at the beginning of this presentation.
These could all be gathered into just one place in the legislation,
thereby allowing more careful fulfilling of the safeguards,
especially if they were named and/or numbered.
The documents proving that the safeguards have been fulfilled
could be gathered and numbered in the same order as they appear in the law.

    Whenever critics of the proposed legislation raise doubts about the safeguards,
each safeguard could be evaluated on it own merits and weaknesses.
Doubts could be raised about how each safeguard might be applied.
Whenever such doubts are valid, that safeguard could be strengthened.

    Gathering all of the safeguards into one location in any proposed bill
will aid the legislative process for making a new law.
Instead of merely rejecting all of the safeguards as weak and useless,
opponents would be called upon to address each safeguard individually.
Would this safeguard prevent the mistakes and abuses they fear?

    Also, any new law based on Quebec's right-to-die law
should make sure all safeguards apply to all the named methods of dying.

    Here is an example of proposed legislation
that does put all 26 recommended safeguards into one section of the law:
http://www.tc.umn.edu/~parkx032/PREM-DTH.html.


 


If you are a legislator from another province of Canada,
here are some explicit suggestions for improving Quebec's right-to-die law:
https://s3.amazonaws.com/aws-website-jamesleonardpark---freelibrary-3puxk/SG-CAN.html
These ways to making a better law include
putting all of the safeguards into one section of the law
and naming all five medical methods of managing dying.



Go to a listing of safeguards used in other places:

Safeguards as Found in Various Laws and Proposed Laws.



Here is an earlier version of this law---called Bill 52---
which has been slightly revised for the law above.



Go to the beginning of this website
James Leonard Park—Free Library



Created April 28, 2016; Revised 4-29-2016;