Medical Assistance in Dying in Canada: A Multidisciplinary Pan-Canadian Delphi Study to Inform Clinical Practice Documents and Plan a Research Agendas

Medical Assistance in Dying in Canada: A Multidisciplinary Pan-Canadian Delphi Study to Inform Clinical Practice Documents and Plan a Research Agendas | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Medical Assistance in Dying in Canada: A Multidisciplinary Pan-Canadian Delphi Study to Inform Clinical Practice Documents and Plan a Research Agendas Melissa Henry, Justine Albert, Sabrina Chan Chun Kong, James Downar, and 22 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8206322/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Objective: Standardized protocols for assessing and addressing patient suffering are absent from Canadian clinical practice documents on medical assistance in dying (MAiD). Our Delphi study aimed to seek expert consensus on potential improvements to clinical practice documents and on research priorities to address suffering in MAiD. Methods: A multidisciplinary panel of 54 experts from across Canada participated in a modified e-Delphi study. Three rounds of surveys were conducted after a national knowledge dissemination meeting. Results: There was agreement on 27 clinical practice document revisions and on 24 research priorities. Among the main recommendations were early integration of psychosocial and palliative care, providing follow-up and support for patients deemed ineligible for MAiD, addressing mental health stigma, including basic psychosocial assessments in MAiD evaluations, involving social workers when suffering of MAiD requestors is linked to social determinants of health , and clarifying bio-psycho-social-existential issues associated with intolerable suffering (including social determinants of health) in patients requesting MAiD in the context of life-threatening and non-life-threatening conditions. Conclusion: Our results provide practical recommendations for improving MAiD clinical practice documents as they pertain to suffering, as well as identify research priorities to pursue. Our experience can inform clinical policies in Canada and other countries where MAiD is legal or being considered. Cancer Oncology Canada Delphi Technique Guidelines Psychosocial Care Palliative Care Medical Assistance in Dying Figures Figure 1 Background In the Canadian context, MAiD is available to people living with serious illness whose physical or psychological suffering is enduring and judged intolerable despite attempts at relief. To provide informed consent, individuals must understand their diagnosis and prognosis, the treatments that are available, and options to ease suffering, including palliative care (1,2). In practice, the reasons people ask for MAiD often extend beyond physical symptoms to encompass psychological, social, and existential concerns such as loss of autonomy, dignity, and participation in meaningful activities (3-5). Existing work in Canada and other MAiD-permissive jurisdictions suggests that these different layers of suffering are not always systematically assessed or addressed in routine practice. Although some forms of suffering that drive MAID requests may be amenable to palliative or psychosocial interventions (6,7), a previous scoping review of 537 clinical practice documents from three Canadian provinces has shown that these are not consistently embedded in policy documents regarding MAiD (8). Assessing and addressing unbearable suffering can be complex, as reported in other jurisdictions allowing euthanasia and physician-assisted suicide (2). We conducted a national expert Delphi study to achieve consensus on how to improve clinical practice documents and what research should be conducted on suffering in MAiD. The goal was to help create clear, actionable ways to improve MAiD practice documents. Methods Design. Our Delphi exercise was embedded in a broader knowledge-translation initiative. As a first step, we convened a two-day virtual national meeting (July 14–15, 2022) that brought together clinicians, researchers, people with lived experience, policy-makers, and other stakeholders from across Canada and abroad. The meeting had three main aims: to share findings from an earlier scoping review of clinical practice documents on suffering in MAiD (8), to discuss how current eligibility criteria and practice documents handle the assessment and relief of suffering, and to generate concrete suggestions for revising clinical guidance and for building a national research agenda on MAiD-related suffering. The goal was to discuss patients requesting MAiD in both Track 1 and 2, with an emphasis on Track 1 cases since MAiD practice was mostly conducted within this context at the time of the meeting. A detailed description of the meeting’s structure and content has been published elsewhere and is not repeated here (9). We drew on the Dialogue Model (10-12), a participatory framework for knowledge transfer and priority-setting, to structure this project. In brief, the model emphasizes iterative exchange between stakeholders, explicit attention to the messages being communicated, and careful planning of the processes used to move from evidence to shared priorities. In our case, it guided the preparatory work (review of existing evidence and stakeholder engagement), the design of the national meeting, and the subsequent steps of refining and prioritizing candidate recommendations for practice and research. A fuller description of how the Dialogue Model was applied in this initiative is available in our previously published report (9). All plenary and breakout discussions from the national meeting were recorded and transcribed. Using thematic analysis (13), the research team identified participants’ suggestions (n=79) into a set of candidate 37 changes to clinical practice documents and 42 potential research priorities. These were grouped under 15 overarching themes and then reformulated as survey items for the Delphi process conducted according to established guidelines (10,11) and included in three iterative rounds of online surveys (12), preserving participants’ wording where possible. Participants. For the Delphi panel, we invited individuals who had participated in the national meeting as well as additional experts suggested by them (i.e., snowball sampling). Eligible panellists were clinicians, researchers, policy-makers, and people with lived experience (e.g., patients or family caregivers) who were experienced in end-of-life (including palliative care, MAiD, and suicide prevention). There is currently no consensus on the ideal number of participants for a Delphi study (11,14); with suggested heterogeneous sample sizes of 15 to 100 to ensure representation of the entire spectrum of opinions. We aimed for a heterogeneous panel of approximately 40-55 members (12,14,15), consistent with guidance for Delphi studies that seek to capture a broad range of perspectives. There was diversity on profession (e.g., palliative care, intensive care, emergency medicine, family physician, nurse, physiotherapy, occupational therapy, spiritual care, psychiatrist, psychologist, social worker), geographic region, disease focus (e.g., cancer, neurological, cardiovascular), and practice setting (e.g., hospital, community setting). Procedure and data collection. Across three online survey rounds, panel members rated the importance of each proposed item on a 5-point Likert scale (1 = not important to 5 = very important) (11,16). In round one, the survey also included open-ended questions that allowed respondents to suggest additional items, comment on wording, and describe perceived barriers, facilitators, and knowledge-translation tools. For rounds two and three, participants were shown anonymized summaries of the group’s ratings from the previous round and were invited to reconsider their own ratings in light of this feedback (12). Consistent with prior Delphi work, we defined consensus a priori as at least 70% of respondents rating an item as important or very important (score of 4 or 5). To accommodate differences in expertise, panellists were not required to rate every item. At the end of the Delphi process, interested participants joined follow-up meetings to discuss how high-priority items could be translated into concrete wording for clinical practice documents. Ethics and consent to participate declaration. This study was approved by McGill University’s Research Ethics Board. Informed consent was obtained from all participants. Data is available upon request.Authors consent to publication in BMC Palliative Care. There are no competing interests in regards of this study. This study was funded through a grant from the Canadian Institutes of Health Research (CIHR), the Quebec Research Network on Palliative and End of Life Care (RQSPAL), and the Centre for Research and Intervention on Suicide and End of Life Practices (CRISE). Data Analysis Quantitative data were analyzed using SPSS 29. Media scores, means, and frequency distributions were calculated for each Likert-scale item. Chi-Square tests explored ratings across subgroups (inter-differences in percentage of consensus ratings among clinicians, researchers, and policymakers). Qualitative content analysis was conducted using Nvivo 12 with two coders (JA and SCCK) and a senior reviewer (MH), who coded responses from the meeting and open-ended survey questions, developing clinical practice document changes and research priorities from descriptive codes aligned with participants’ original text. These clinical practice document changes and research priorities were thematically combined under overarching themes in the analysis. Data from participants were included for each round in the analysis. Results Participants. The final panel comprised 54 experts from six Canadian provinces (out of the 74 people invited; overall response rate 74%), including 23 researchers (43%), 21 clinicians (39%), 9 policy-makers (17%), and 1 participant who identified primarily as a patient/family caregiver (2%). Thirty-two participants had been part of the 2-day virtual Knowledge Dissemination and Research Planning Meeting and 22 were referred by group members. Sixty-three percent of participants (n= 34) identified as women and 37% (n= 20) as men. Just over half were based in Quebec (51%; n=27), with the remainder mainly from Ontario (25%; n=13) and British Columbia (19%; n=10). Consensus was reached for 27 of the 38 proposed changes to clinical practice documents and for 24 of the 51 research priorities. Priority themes. Of the 15 themes, 12 themes (80.0% of all themes) reached consensus and were considered a priority. Top-rated themes included: Early integration of palliative and psychosocial care (89% consensus) Supporting patients throughout the 90-day wait period before MAiD is accepted (86%) Addressing the complexity of mental health comorbidities (84%) Incorporating social determinants of health into MAiD assessments (79%) Promoting culturally competent models of care (79%) Creating a core set of standards and ensuing quality indicators for palliative care (79%) Offering supportive care for people suffering from non-life-threatening condition (79%) See Table 2 for top-rated themes and Suppl. Material Table 1 for overall themes that did not reach consensus. Clinical practice document improvements. Out of the 38 clinical practice document improvement items that were not currently covered in clinical practice documents, 27 (71.1%) achieved consensus and were deemed priorities to integrate into policy. Top rated clinical practice document improvements included: Offering psychosocial care at diagnosis and at key moments during the disease trajectory (92% consensus) Considering a palliative approach early in care planning (89%) Providing follow-up and support for patients deemed ineligible for MAiD (84%) Addressing mental health stigma (84%) Including basic psychosocial assessments in MAiD evaluations (79%) Involving social workers when suffering of MAiD requestors is linked to social determinants of health (79%) Clarifying bio-psycho-social-existential issues associated with intolerable suffering (including social determinants of health) in patients requesting MAiD in the context of life-threatening and non-life-threatening conditions (79%) See table 3 for top-rated clinical practice document change items and Suppl. Material Table 2 for items that did not reach consensus. Research priorities. Of the 51 research items, 24 (47.1%) achieved consensus and were deemed priorities for a research agenda on MAiD. Top research priorities included: Understanding patients’ perspectives on suffering and how it evolves over time (95% consensus) Studying the role of mental health stigma in MAiD care (87%) Assessing how early palliative care affects MAiD requests (85%) Exploring why patients delay or reconsider MAiD after initial requests (82%) Improving communication around suffering within MAiD discussions (79%) Understanding the influence of cultural factors on MAiD requests, use of palliative care services, and the assessment of suffering (79%) See table 4 for top-rated research priority items and Suppl. Material Table 3 for items that did not reach consensus. Implementation barriers, facilitators, and tools . Most participants perceived their workplace as moderately (46%) or totally (35%) willing to adopt the consensus improvements. Key facilitators included leadership support, patient-clinician partnerships, educational resources on MAiD practice, and policy development by ministries of health, regulatory colleges, and CAMAP board. Barriers included time constraints, limited access to psychosocial services, inconsistent provincial policies, stigma towards MAiD in society, and fear of mistaking a valid request for MAiD with one based on social determinants of health. Eighty-two percent of participants were moderately willing (40%) or totally willing (43%) to disseminate these consensus improvements in their workplaces. They reported needing online training tools (e.g., short digestible videos and webinars), printable documents/materials, PowerPoint slides, and financial support. At the end of the Delphi study, participants regrouped together for a series of three meetings to discuss concrete clinical practice changes that could be integrated into clinical practice documents. The suggestions are presented in Suppl. Material Table 5 and in the following report: https://www.recherchesoinspalliatifs.ca/wp-content/uploads/2024/03/MH24004-RM_AssDying_V6.pdf. Themes according to participant group (clinicians, researchers, and policymakers). The ratings of 22 items of the total number of items (clinical and research) differed significantly between participant groups. (see Suppl. Material Table 4 for inter-group differences based on independent samples t test). When considered together, the Delphi process’s priorities indicate a need to improve clinical practice documents in several key areas as they pertain to evaluating and addressing suffering of people requesting MAiD. They also identify key research priorities to pursue in the field. Discussion This study provides consensus recommendations for the ideal content of MAiD clinical practice documents. It outlines the importance of comprehensively assessing and supporting psychological, existential, social, and cultural factors that may be contributing to a MAID request. The strongest signal from the panel concerned timing: participants wanted palliative and psychosocial support to be introduced much earlier in the course of illness, rather than only once MAiD is being considered. This recommendation aligns with the broader palliative care literature, where timely involvement of palliative and supportive care has been shown to enhance quality of life and, in some cases, even survival (17). Psychosocial interventions throughout the MAiD process may alleviate some of the suffering and prolong meaningful life; this is a benefit regardless of whether the person ultimately proceeds with MAID or not. It also aligns with the Lancet Oncology Commission on the Human Crisis of Cancer, a call to increase attention to the humanistic dimensions of cancer care (18). Quality palliative care indicators could be integrated into MAiD workflows (8) so that suffering is fully explored and addressed before moving forward as well as support provided throughout the wait time from the moment of a request on. The potential stigma of palliative care services would be important to mitigate, perhaps through psychoeducation (19, 20), and a recovery-oriented approach (21). Including psychosocial care from the moment of a medical diagnosis, alongside quality indicators for psychosocial health, was considered a standard of quality cancer care (22-25). Descriptions of clinical assessments in clinical practice documents can better reflect the complexity of suffering by including evidence-based psychosocial interventions and clinical practice guidelines. Harnessing the strengths of multidisciplinary teams can help provide more complete patient-centered care. Panelists also emphasized that MAiD assessments should pay systematic attention to social determinants of health. Unmet needs such as poverty, isolation, and systemic barriers can contribute to suffering. By systematically exploring these factors, MAiD assessors and providers can ensure decisions are based on end-of-life preferences rather than social constraints. Improved health literacy and reduced stigma around palliative care could increase service acceptance, particularly among marginalized groups (26,27). Another recurring theme was the need for culturally responsive care, particularly in a country as diverse as Canada (28-30). Practice documents should clearly explain how to deal with cultural beliefs and values around suffering, dying, and medical decisions making (29). Lastly, research priorities included further understanding the suffering behind MAiD requests, how patients make decisions around MAiD, and how early palliative interventions affect these decisions. Future research should investigate psychosocial interventions commonly used, care models that are culturally sensitive, and structured support for both patients and providers who are making MAiD decisions (31-33). Recommendations from this study may help to address gaps in clinical practice documents, uphold ethical standards, and ensure patient-centered care in the MAiD context. Implementation strategies for these recommendations could include new clinical guidelines, continuing professional education, and the collection of quality metrics that assess how MAID assessors and providers address these recommendations in practice. Potential Limitations. Several limitations must be noted. First, virtual data collection methods may have limited participant engagement and influenced responses due to distractions and lack of verbal cues (34). Second, while diverse, the range of perspectives among stakeholders, especially on a topic such as MAiD, may have challenged consensus on certain items. Future research should consider delving deeper into the varying perspectives of clinicians, researchers, and policymakers. It should also more clearly delineate issues related to how suffering is addressed in Track 1 and Track 2 patients, as well as serve to fuel the discussion in other contexts that are likely affected by the law’s enlargement (e.g., anticipated directives, mental health, minors). Third, most stakeholder participants were from Quebec and assessing and providing MAiD in Quebec occurs under provincial as well as federal legislation. While we think that the recommendations could be equally applicable to other parts of Canada, we acknowledge that there may be regional differences to eventually consider such as variability in resource availability. There could also be restrictions in resources that are regionally available. Fourth, we strove to include a variety of stakeholders in the Delphi study, and our sample was comprised mostly of professionals and policy makers. However, it is possible that some professionals and policy makers have also had lived experience with MAiD in their personal circle. This study could eventually be repeated with a focus on people with lived experience of MAiD (patients and family members). Finally, item formulation could have impacted consensus, as some items had content that referred to combined MAiD and palliative contexts potentially influencing acceptability ratings. Further qualitative studies could clarify why certain items did not reach consensus. Conclusion The Delphi study’s conclusions offer recommendations for the content of MAiD practice guidelines and research, including content relevant to early psychosocial and palliative care interventions, considering social determinants of health, and using culturally sensitive, interdisciplinary assessments to clinical practice documents if they are not already present. We hope that standardizing the content of practice documents will help ensure that MAiD practice is fair, ethical, and patient-focused. We recommend that MAID programs review their clinical documents and policies to identify any current gaps, and that assessors pursue specific training to address areas where they might have learning needs. Apart from the research priorities identified in this study, future research should examine how these changes are implemented and how they affect patient outcomes and quality of care. Declarations Funding declaration This study was supported through a grant from the Canadian Institutes of Health Research (CIHR), the Quebec Research Network on Palliative and End of Life Care (RQSPAL), and the Centre for Research and Intervention on Suicide and End of Life Practices (CRISE). Conflict of interest declaration There are no competing interests in regards of this study. Availability of data and material declaration The datasets related to the current study are available from the corresponding author upon reasonable request. Authors contributions All authors were involved in the conceptualization, methodology, and writing/editing of the study. MH was involved in funding acquisition. Ethics approval and consent to participate declarations This study was approved by McGill University’s Research Ethics Board. This study adhered to the Declaration of Helsinki. Informed consent was obtained from all participants. Consent for publication declaration Not applicable. References Government of Canada. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). 2016. Available from: https://laws-lois.justice.gc.ca/fra/LoisAnnuelles/2016_3/TexteComplet.html Dees M, Vernooij M, Dekkers W, van Weel C. Unbearable suffering of patients with a request for euthanasia or physician-assisted suicide: an integrative review. 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Baseline Characteristic n % Sex Female 34 63% Male 20 37% Gender Woman 34 63% Man 20 37% Age 20-30 4 7% 31-40 8 15% 41-50 15 28% 51-60 13 24% 61-70 10 19% 71-80 4 7% Ethnicity Caucasian/ European 38 70% South Asian 2 4% Chinese 3 6% No response 11 20% Level of Education College Diploma 9 17% University Diploma 5 9% Professional School 15 28% Graduate Education 24 44% No response 1 2% Connection to MAiD Researcher 23 43% Clinician 21 39% Policy-Maker 9 17% Family Caregiver 1 2% Province / Territory Quebec 27 50% Ontario 13 24% British Columbia 10 19% Saskatchewan 1 2% Manitoba 1 2% Nova Scotia 1 2% No response 1 2% Table 2. Overall overarching themes that reached consensus. Overarching Theme Round 1 Mean (Median) % n=46 Round 2 Mean (Median) % n=53 Round 3 Mean (Median) % n=54 Introducing palliative and psychosocial care services early in the disease trajectory Description: Practice guidelines for most serious and incurable illnesses emphasize the importance of early or timely integration of palliative and psychosocial care services. There are barriers to timely integration of palliative and psychosocial care, including stigmata vis-à-vis opioids, palliative care, and mental health. There may be ways to address these barriers, including psychoeducation, patient representatives, and a recovery-oriented approach. 4.54 (5.00) 89% -- -- Maintaining supportive care during the 90-day wait period until MAiD is accepted. Description: Healthcare providers have an obligation to provide ongoing care, including any indicated treatments, to patients who have requested MAID. Continuity of care may help improve suffering, which is beneficial even if the person ultimately proceeds with MAID. 4.27 (4.00) 86% -- -- Reflect complexity in the evaluation of patients with mental health comorbidities requesting MAiD. Description: Patients requesting MAiD may have underlying comorbid psychiatric illnesses that may be unidentified or undertreated by the care team. MAiD assessors and providers are in a position to identify and help manage such illnesses and ensure that alternatives to MAiD have been offered. 4.26 (4.00) 84% -- -- Social determinants of health need to be integrated into the evaluation of MAiD requests. Socio-economic deprivation and other forms of structural disadvantage can contribute to suffering and may be challenging to assess and address. Stigmatization and poor health literacy may also play a role in patients refusing palliative and psychosocial interventions. Different models need to be envisaged to increase access to care. 4.34 (5.00) 79% -- -- Develop a model for MAiD that is culturally competent. Description: Medical education is paying increasing attention to cultural competency and sensitivity to diversity. Considerations of culture and diversity may be important when evaluating how patients, caregivers, and healthcare practitioners envision life, death, suffering, and the role of medicine. 4.29 (5.00) 79% -- -- Create a core set of standards and ensuing quality indicators for palliative care specifically in Canada to be integrated into the general monitoring system for end-of-life care. Description: There is a need to develop standards and quality indicators for palliative care in Canada, allowing the country to initiate palliative care quality improvement and monitor quality end-of-life care. These indicators would be used throughout the provision of care in all major disease trajectories (e.g., cancer, cardiovascular, neurodegenerative disease). A core set of quality indicators would constitute standards for palliative care that are enforced through Accreditation Canada. These indicators are needed in all places where people receive care for chronic life-threatening illnesses, and need to be assessed again at the time of MAiD requests and can serve to inform care options provided or offered during MAiD assessments. 4.24 (4.00) 79% -- -- Offer supportive care for people suffering from non-life-threatening conditions. Description: Additional safeguards are needed for patients whose deaths are not reasonably foreseeable, such as consultation of physicians specializing in the disease being treated, a 90-day assessment period, and access to supportive care addressing physical, psychological and existential symptoms with practical support. 4.13 (4.00) 79% -- -- Offer interventions based on hope, dignity, and maintaining a sense of autonomy/control. Description: MAiD requests are often based on existential distress and a loss of a sense of control and autonomy. Interventions focused on these threats may help improve their suffering, whether they chose to proceed with MAiD. 3.97 (4.00) 66% 4.18 (4.00) 77% -- Implementing an interdisciplinary approach to the care of a patient requesting MAiD. Description: The suffering that motivates MAiD requests is due to a combination of physical, psychological, practical/social, and existential issues. Considering the nature of suffering in MAiD, there may be a benefit to integrating an interdisciplinary approach in assessment and management of MAiD requests, including palliative care, psychiatrists, psychologists, social workers, nurse practitioners, physiotherapists, occupational therapists, and spiritual counselors. Continuity of care is a priority. 4.24 (5.00) 76% -- -- Normalize palliative care as part of health care to help destigmatize it. Description: The stigma surrounding palliative care may prevent individuals from utilizing palliative care themselves or from enrolling family members. A public health strategy with media campaigns designed to educate the public on palliative care in a way that associates it with life and promotes hopefulness may be helpful in overcoming this stigma. 4.08 (4.00) 74% -- -- Consider the effect of MAiD on healthcare provider burnout and emotional and psychological distress. Description: Burnout in healthcare professionals has been increasing, especially following the onset of the COVID-19 pandemic. In the context of MAiD, healthcare providers can sometimes face challenges navigating patients’ requests and adapting to changes in Canada’s MAiD legislation. Providers may experience distress because of participating in MAiD assessment and provision, or as a result of being prevented from participating in MAiD assessment and provision (either through institutional policies or other means). Both participation and non-participation may conflict with a provider’s values and beliefs. There is a need to ensure that healthcare providers are supported regardless of their involvement in MAiD. 3.95 (4.00) 68% 3.90 (4.00) 69% 4.02 (4.00) 74% Create a core set of existential / psychosocial indicators to be integrated into the monitoring system for end-of-life care. Description: According to the Annual Report on MAiD in Canada, MAiD requests are motivated principally by existential and psychological distress. There are validated measures of psychological and existential distress available, and some interventions may be effective to address this distress. Included in palliative care indicators, it would be important to develop a core set of psychosocial care quality indicators. 4.08 (4.00) 70% -- -- Table 3. Changes to guiding MAiD clinical practice documents at a policy level that reached consensus to guide clinical care. Items Round 1 Mean (median) % Round 2 Mean (median) % Round 3 Mean (median) % Offer psychosocial care for identified distress as early as the onset of diagnosis and at crucial times during the disease trajectory. 4.45 (5.00) 92% -- -- Consider and discuss a palliative approach as early as the onset of diagnosis. 4.34 (4.50) 89% -- -- Integrate follow-up and support for patients found to be ineligible for MAID at the time of the assessment. 4.26 (4.00) 84% -- -- Address stigma towards mental health in patients requesting MAiD. 4.21(4.00) 84% -- -- Integrate standards and quality indicators for palliative care specifically in Canada. 4.24 (4.00) 81% -- -- Integrate a core set of existential / psychosocial care quality indicators in Canada. 3.97 (4.00) 81% -- -- Include a basic psychosocial needs assessment within the context of a MAiD request, considering both patient and family needs. 4.24 (4.00) 79% -- -- Involve a social worker and other psychosocial professionals when the MAiD evaluation reveals that social determinants of health are a significant component of suffering. 4.24 (4.50) 79% -- -- Clarify bio-psycho-social-existential issues associated with intolerable suffering (including social determinants of health) in patients requesting MAiD in the context of life-threatening and non-life-threatening conditions. 4.21 (4.00) 79% -- -- Mention interventions that may be effective to address existential and psychosocial distress in a patient requesting MAID. 4.18 (4.00) 79% -- -- Reinforce the importance of providing or continuing support for patients and caregivers during the 90-day wait period for MAiD acceptance via community resources and psychological assistance. 4.13 (4.00) 79% -- -- Include a core set of brief validated measures for psychological, practical/social, and existential distress for MAID assessors to use in their evaluation of MAiD requests. 3.79 (4.00) 66% 4.00 (4.00) 79% -- Underscore the importance of identifying those who would be at risk of suicide if deemed ineligible for MAiD. 3.79 (4.00) 61% 4.08 (4.00) 77% -- Implement explanations related to shared decision-making and advanced directives for MAiD requestors as a means to foster a sense of control and autonomy. 3.90 (4.00) 68% 4.03 (4.00) 77% -- Integrate the evaluation of social determinants of health as part of a MAiD assessment. 4.21 (4.00) 76% -- -- Outline the various treatment options (pharmacologic, psychotherapy) available for psychiatric illness and psychological distress in patients requesting MAiD. 4.18 (4.50) 76% -- -- Evaluate suicidality, and whether suicidality may be affecting a wish to hasten death in patients requesting MAiD. 4.05 (4.00) 74% -- -- Refer to educational curriculum venues for MAiD assessors and providers that comprehensively covers evaluating and addressing suffering in patients requesting MAiD. 4.03 (4.00) 74% -- -- Address issues of cultural competency and sensitivity to diversity in addressing how patients, caregivers, and healthcare practitioners envision life, death, suffering, and the role of medicine in the context of a MAiD request. 4.13 (4.00) 74% -- -- Integrate diagnostic tools to evaluate mental health comorbidities in patients requesting MAiD. 3.95 (4.00) 74% -- -- Integrate strategies to prevent and manage MAiD healthcare provider burnout, such as providing organizational and mental health support. 4.00 (4.00) 66% 3.92 (4.00) 69% 4.04 (4.00) 73% Establish clear roles, responsibilities, and clinical pathways for each member of the interdisciplinary care team to assess and address suffering in MAiD requests. 4.03 (4.50) 68% 4.08 (4.50) 72% -- Integrate current evidence-based palliative and supportive care guidelines for management of symptoms and distress into the process of MAiD assessment and provision. 3.97 (4.00) 68% 3.97 (4.00) 72% -- Establish care models that could be used when resources are lacking to address unbearable suffering in the context of MAiD requests. 4.13 (4.00) 71% -- -- Integrate an evaluation of unmet needs related to social determinants of health underlying unbearable suffering in MAiD requests and indicate whether treatment and therapies exist and are available to the patient, at the hospital and community levels. 4.18 (5.00) 71% -- -- Include dignity measures and exploration of patients’ suffering during MAiD evaluations. 3.92 (4.00) 63% 3.92 (4.00) 69% 4.00 (4.00) 71% Integrate the systematic evaluation of depression and suicidal ideation in the assessment of MAiD requests. 3.92 (4.00) 71% -- -- Table 4. Research priorities that reached consensus. Items Round 1 Mean (median) % n=46 Round 2 Mean (median) % n=53 Round 3 Mean (median) % n=54 Better understand the perspectives of patients with respect to different forms of suffering, their influence on MAiD requests, and how they change over the course of the MAiD trajectory (psychological, practical/social, existential, physical). 4.47 (5.00) 95% -- -- Identify how mental health stigma affect the provision of optimal care in the context of MAiD. 3.92 (4.00) 69% 4.21 (4.00) 87% -- Determine the impact of an early/timely palliative approach on requests for MAiD. 3.92 (4.00) 68% 4.21 (4.00) 85% -- Understand what triggers a patient to delay MAiD or change their mind about MAiD following a request. 3.87 (4.00) 68% 4.08 (4.00) 82% -- Better understand how doctor-patient communication best practices are applied to conversations around suffering within a MAiD request. 3.73 (4.00) 65% 4.23 (4.00) 79% -- Understand the influence of cultural factors on MAiD requests, use of palliative care services, and the assessment of suffering. 4.16 (4.00) 79% -- -- Develop effective, scalable, and acceptable treatments for existential and psychosocial distress in the context of MAiD requests. 4.05 (4.00) 79% -- -- Understand the impact of social and cultural factors on the interpretation of suffering from the perspective of patients, families, and healthcare practitioners when MAiD is requested. 4.08 (4.00) 76% -- -- Understand suffering in the context of MAiD requests associated with non-life-threatening conditions and how this suffering changes with time. 4.08 (4.00) 76% -- -- Develop an educational curriculum for MAiD assessors and providers that comprehensively covers evaluating and addressing suffering. 4.05 (4.00) 76% -- -- Better understand MAiD assessors’ and providers’ knowledge and skills in regard to complex assessments of suffering within MAiD requests. 4.05 (4.00) 74% -- -- Engage national leaders and stakeholders to develop and enact a public health strategy on palliative care. 4.03 (4.00) 68% 4.10 (4.00) 74% -- Understand the relative contribution of social determinants of health to suffering underlying track 1 versus track 2 MAiD requests. 4.05 (4.00) 74% -- -- Better understand health service utilization when patients are found ineligible for MAID, 3.79 (4.00) 63% 4.05 (4.00) 74% -- Evaluate the effect of treating underlying psychiatric illness on suffering reported by people requesting MAiD. 4.03 (4.00) 74% -- -- Develop a core set of validated quality indicators for existential / psychosocial care in Canada to be integrated into the MAiD monitoring system through Health Canada and the Canadian Institute of Health Information. 3.79 (4.00) 61% 3.92 (4.00) 74% -- Better understand the perspectives of MAiD clinicians with respect to different forms of suffering, their influence on MAiD requests, and how they change over the course of the MAiD trajectory (psychological, practical/social, existential, physical). 3.89 (4.00) 74% -- -- Better understand the perspectives of family caregivers with respect to different forms of suffering, their influence on MAiD requests, and how they change over the course of the MAiD trajectory (psychological, practical/social, existential, physical). 3.84 (4.00) 74% -- -- Understand burnout in MAiD assessors and providers, how suffering is addressed, and the impact on clinical practice. 3.84 (4.00) 66% 3.82 (4.00) 67% 3.94 (4.00) 73% Better understand the impact of early conversations around MAiD on a sense of control and the eventual. 3.81 (4.00) 59% 3.85 (4.00) 69% 3.96 (4.00) 72% Develop and evaluate a model of care that emphasizes support throughout the 90-day wait period for people requesting MAiD by track 2. 3.84 (4.00) 66% 3.95 (4.00) 72% -- Understand how hope and hopelessness are addressed in patients requesting MAiD. 3.86 (4.00) 68% 3.95 (4.00) 72% -- Determine the impact of early and timely psychosocial care on requests for MAiD. 4.08 (4.00) 71% -- -- Characterize how the nature of suffering in the context of MAiD requests associated with non-life-threatening conditions may be different from that of MAiD requests associated with a life-threatening condition. 3.92 (4.00) 71% -- -- Understand the extent to which knowledge of certain care processes (e.g., advanced directives, palliative sedation) provide patients with a sense of control and change their minds as to MAiD. 3.76 (4.00) 66% 3.79 (4.00) 69% 3.86 (4.00) 71% Additional Declarations No competing interests reported. Supplementary Files ManuscriptMAiDDelphiSept32025SupplMaterial.docx Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 26 Jan, 2026 Reviews received at journal 16 Jan, 2026 Reviews received at journal 15 Jan, 2026 Reviewers agreed at journal 05 Jan, 2026 Reviewers agreed at journal 04 Jan, 2026 Reviewers agreed at journal 04 Jan, 2026 Reviewers invited by journal 04 Jan, 2026 Editor assigned by journal 04 Jan, 2026 Editor invited by journal 22 Dec, 2025 Submission checks completed at journal 17 Dec, 2025 First submitted to journal 17 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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1","display":"","copyAsset":false,"role":"figure","size":514995,"visible":true,"origin":"","legend":"\u003cp\u003eDot plot of consensus on MAiD clinical practice improvements.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8206322/v1/8d80948d15dbcff98498f8bc.png"},{"id":100356154,"identity":"a5aca8e3-1b91-4b79-b5dc-718e5a6fbf75","added_by":"auto","created_at":"2026-01-16 06:54:04","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2169883,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8206322/v1/cbc75fa8-222d-4eea-9539-895a85207f74.pdf"},{"id":99636585,"identity":"1e42934c-2cc4-4609-92cc-7e1c93af6348","added_by":"auto","created_at":"2026-01-06 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To provide informed consent, individuals must understand their diagnosis and prognosis, the treatments that are available, and options to ease suffering, including palliative care (1,2). In practice, the reasons people ask for MAiD often extend beyond physical symptoms to encompass psychological, social, and existential concerns such as loss of autonomy, dignity, and participation in meaningful activities (3-5). Existing work in Canada and other MAiD-permissive jurisdictions suggests that these different layers of suffering are not always systematically assessed or addressed in routine practice.\u003c/p\u003e\n\u003cp\u003eAlthough some forms of suffering that drive MAID requests may be amenable to palliative or psychosocial interventions\u0026nbsp;(6,7), a previous scoping review of 537 clinical practice documents from three Canadian provinces has shown that these are not consistently embedded in policy documents regarding MAiD (8). Assessing and addressing unbearable suffering can be complex, as reported in other jurisdictions allowing euthanasia and physician-assisted suicide (2).\u003c/p\u003e\n\u003cp\u003eWe conducted a national expert Delphi study to achieve consensus on how to improve clinical practice documents and what research should be conducted on suffering in MAiD. The goal was to help create clear, actionable ways to improve MAiD practice documents.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eDesign.\u003c/em\u003e Our Delphi exercise was embedded in a broader knowledge-translation initiative. As a first step, we convened a two-day virtual national meeting (July 14–15, 2022) that brought together clinicians, researchers, people with lived experience, policy-makers, and other stakeholders from across Canada and abroad. The meeting had three main aims: to share findings from an earlier scoping review of clinical practice documents on suffering in MAiD (8), to discuss how current eligibility criteria and practice documents handle the assessment and relief of suffering, and to generate concrete suggestions for revising clinical guidance and for building a national research agenda on MAiD-related suffering. The goal was to discuss patients requesting MAiD in both Track 1 and 2, with an emphasis on Track 1 cases since MAiD practice was mostly conducted within this context at the time of the meeting.\u0026nbsp;A detailed description of the meeting’s structure and content has been published elsewhere and is not repeated here (9).\u003c/p\u003e\n\u003cp\u003eWe drew on the Dialogue Model (10-12), a participatory framework for knowledge transfer and priority-setting, to structure this project. In brief, the model emphasizes iterative exchange between stakeholders, explicit attention to the messages being communicated, and careful planning of the processes used to move from evidence to shared priorities. In our case, it guided the preparatory work (review of existing evidence and stakeholder engagement), the design of the national meeting, and the subsequent steps of refining and prioritizing candidate recommendations for practice and research. A fuller description of how the Dialogue Model was applied in this initiative is available in our previously published report (9).\u003c/p\u003e\n\u003cp\u003eAll plenary and breakout discussions from the national meeting were recorded and transcribed. Using thematic analysis (13), the research team identified participants’ suggestions (n=79) into a set of candidate 37 changes to clinical practice documents and 42 potential research priorities. These were grouped under 15 overarching themes and then reformulated as survey items for the Delphi process conducted according to established guidelines (10,11) and included in three iterative rounds of online surveys (12), preserving participants’ wording where possible.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eParticipants.\u0026nbsp;\u003c/em\u003eFor the Delphi panel, we invited individuals who had participated in the national meeting as well as additional experts suggested by them\u0026nbsp;(i.e., snowball sampling). Eligible panellists were clinicians, researchers, policy-makers, and people with lived experience (e.g., patients or family caregivers) who were experienced in end-of-life (including palliative care, MAiD, and suicide prevention).\u0026nbsp;There is currently no consensus on the ideal number of participants for a Delphi study (11,14); with suggested heterogeneous sample sizes of 15 to 100 to ensure representation of the entire spectrum of opinions. We aimed for a heterogeneous panel of approximately 40-55 members (12,14,15), consistent with guidance for Delphi studies that seek to capture a broad range of perspectives. There was diversity on profession (e.g., palliative care, intensive care, emergency medicine, family physician, nurse, physiotherapy, occupational therapy, spiritual care, psychiatrist, psychologist, social worker), \u003cstrong\u003egeographic region, disease focus\u0026nbsp;\u003c/strong\u003e(e.g., cancer, neurological, cardiovascular), and practice setting (e.g., hospital, community setting).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eProcedure and data collection.\u003c/em\u003e Across three online survey rounds, panel members rated the importance of each proposed item on a 5-point Likert scale (1 = not important to 5 = very important) (11,16). In round one, the survey also included open-ended questions that allowed respondents to suggest additional items, comment on wording, and describe perceived barriers, facilitators, and knowledge-translation tools. For rounds two and three, participants were shown anonymized summaries of the group’s ratings from the previous round and were invited to reconsider their own ratings in light of this feedback (12). Consistent with prior Delphi work, we defined consensus a priori as at least 70% of respondents rating an item as important or very important (score of 4 or 5). To accommodate differences in expertise, panellists were not required to rate every item. At the end of the Delphi process, interested participants joined follow-up meetings to discuss how high-priority items could be translated into concrete wording for clinical practice documents.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eEthics and consent to participate declaration.\u003c/em\u003e\u003c/strong\u003e \u003cstrong\u003eThis study was approved by McGill University’s Research Ethics Board. Informed consent was obtained from all participants.\u003c/strong\u003eData is available upon request.Authors consent to publication in BMC Palliative Care. There are no competing interests in regards of this study.\u0026nbsp;This study was funded through a grant from the Canadian Institutes of Health Research (CIHR), the Quebec Research Network on Palliative and End of Life Care (RQSPAL), and the Centre for Research and Intervention on Suicide and End of Life Practices (CRISE).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Analysis\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eQuantitative data were analyzed using SPSS 29. Media scores, means, and frequency distributions were calculated for each Likert-scale item. Chi-Square tests explored ratings across subgroups (inter-differences in percentage of consensus ratings among clinicians, researchers, and policymakers). Qualitative content analysis was conducted using Nvivo 12 with two coders (JA and SCCK) and a senior reviewer (MH), who coded responses from the meeting and open-ended survey questions, developing clinical practice document changes and research priorities from descriptive codes aligned with participants’ original text. These clinical practice document changes and research priorities were thematically combined under overarching themes in the analysis. Data from participants were included for each round in the analysis.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipants.\u0026nbsp;\u003c/em\u003eThe final panel comprised 54 experts from six Canadian provinces (out of the 74 people invited; overall response rate 74%), including 23 researchers (43%), 21 clinicians (39%), 9 policy-makers (17%), and 1 participant who identified primarily as a patient/family caregiver (2%).\u0026nbsp;Thirty-two participants had been part of the 2-day\u0026nbsp;virtual Knowledge Dissemination and Research Planning Meeting and 22 were referred by group members.\u0026nbsp;Sixty-three percent of participants (n= 34) identified as women and 37% (n= 20) as men.\u0026nbsp;Just over half were based in Quebec (51%; n=27), with the remainder mainly from Ontario (25%; n=13) and British Columbia (19%; n=10). Consensus was reached for 27 of the 38 proposed changes to clinical practice documents and for 24 of the 51 research priorities.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePriority themes.\u0026nbsp;\u003c/em\u003eOf the 15 themes, 12 themes (80.0% of all themes) reached consensus and were considered a priority.\u0026nbsp;Top-rated themes included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eEarly integration of palliative and psychosocial care (89% consensus)\u003c/li\u003e\n \u003cli\u003eSupporting patients throughout the 90-day wait period before MAiD is accepted (86%)\u003c/li\u003e\n \u003cli\u003eAddressing the complexity of mental health comorbidities (84%)\u003c/li\u003e\n \u003cli\u003eIncorporating social determinants of health into MAiD assessments (79%)\u003c/li\u003e\n \u003cli\u003ePromoting culturally competent models of care (79%)\u003c/li\u003e\n \u003cli\u003eCreating a core set of standards and ensuing quality indicators for palliative care (79%)\u003c/li\u003e\n \u003cli\u003eOffering supportive care for people suffering from non-life-threatening condition (79%)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSee Table 2 for top-rated themes and Suppl. Material Table 1 for overall themes that did not reach consensus.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eClinical practice document improvements.\u0026nbsp;\u003c/em\u003eOut of the 38 clinical practice document improvement items that were not currently covered in clinical practice documents, 27 (71.1%) achieved consensus and were deemed priorities to integrate into policy. Top rated clinical practice document improvements included:\u003c/p\u003e\n\u003cul\u003e\n \u003cli\u003e\u003cstrong\u003eOffering psychosocial care at diagnosis and at key moments during the disease trajectory (92% consensus)\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eConsidering a palliative approach early in care planning (89%)\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eProviding follow-up and support for patients deemed ineligible for MAiD (84%)\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eAddressing mental health stigma (84%)\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eIncluding basic psychosocial assessments in MAiD evaluations (79%)\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003e\u003cstrong\u003eInvolving social workers when suffering of MAiD requestors is linked to social determinants of health (79%)\u003c/strong\u003e\u003c/li\u003e\n \u003cli\u003eClarifying bio-psycho-social-existential issues associated with intolerable suffering (including social determinants of health) in patients requesting MAiD in the context of life-threatening and non-life-threatening conditions (79%)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSee table 3 for top-rated clinical practice document change items and Suppl. Material Table 2 for items that did not reach consensus.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eResearch priorities.\u0026nbsp;\u003c/em\u003eOf the 51 research items, 24 (47.1%) achieved consensus and were deemed priorities for a research agenda on MAiD.\u0026nbsp;Top research priorities included:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eUnderstanding patients\u0026rsquo; perspectives on suffering and how it evolves over time (95% consensus)\u003c/li\u003e\n \u003cli\u003eStudying the role of mental health stigma in MAiD care (87%)\u003c/li\u003e\n \u003cli\u003eAssessing how early palliative care affects MAiD requests (85%)\u003c/li\u003e\n \u003cli\u003eExploring why patients delay or reconsider MAiD after initial requests (82%)\u003c/li\u003e\n \u003cli\u003eImproving communication around suffering within MAiD discussions (79%)\u003c/li\u003e\n \u003cli\u003eUnderstanding the influence of cultural factors on MAiD requests, use of palliative care\u0026nbsp;services, and the assessment of suffering (79%)\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eSee table 4 for top-rated research priority items and Suppl. Material Table 3 for items that did not reach consensus.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eImplementation barriers, facilitators, and tools\u003c/em\u003e. Most participants perceived their workplace as moderately (46%) or totally (35%) willing to adopt the consensus improvements. Key facilitators included leadership support, patient-clinician partnerships, educational resources on MAiD practice, and policy development by ministries of health, regulatory colleges, and CAMAP board. Barriers included time constraints, limited access to psychosocial services, inconsistent provincial policies, stigma towards MAiD in society, and fear of mistaking a valid request for MAiD with one based on social determinants of health. Eighty-two percent of participants were moderately willing (40%) or totally willing (43%) to disseminate these consensus improvements in their workplaces. They reported needing online training tools (e.g., short digestible videos and webinars), printable documents/materials, PowerPoint slides, and financial support. At the end of the Delphi study, participants regrouped together for a series of three meetings to discuss concrete clinical practice changes that could be integrated into clinical practice documents. The suggestions are presented in Suppl. Material Table 5 and in the following report: https://www.recherchesoinspalliatifs.ca/wp-content/uploads/2024/03/MH24004-RM_AssDying_V6.pdf.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eThemes according to participant group (clinicians, researchers, and policymakers).\u003c/em\u003e\u0026nbsp;\u003cbr\u003e\u0026nbsp;The ratings of 22 items\u0026nbsp;of the total number of items (clinical and research)\u0026nbsp;differed significantly between participant groups. (see Suppl. Material Table 4 for inter-group differences based on independent samples t test).\u003c/p\u003e\n\u003cp\u003eWhen considered together, the Delphi process\u0026rsquo;s priorities indicate a need to improve clinical practice documents in several key areas as they pertain to evaluating and addressing suffering of people requesting MAiD. They also identify key research priorities to pursue in the field.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study provides consensus recommendations for the ideal content of MAiD clinical practice documents. It outlines the importance of comprehensively assessing and supporting psychological, existential, social, and cultural factors that may be contributing to a MAID request.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe strongest signal from the panel concerned timing: participants wanted palliative and psychosocial support to be introduced much earlier in the course of illness, rather than only once MAiD is being considered. This recommendation aligns with the broader palliative care literature, where timely involvement of palliative and supportive care has been shown to enhance quality of life and, in some cases, even survival (17).\u0026nbsp;Psychosocial interventions throughout the MAiD process may alleviate some of the suffering and prolong meaningful life; this is a benefit regardless of whether the person ultimately proceeds with MAID or not. It also aligns with the Lancet Oncology Commission on the Human Crisis of Cancer, a call to increase attention to the humanistic dimensions of cancer care (18). Quality palliative care indicators could be integrated into MAiD workflows (8) so that suffering is fully explored and addressed before moving forward as well as support provided throughout the wait time from the moment of a request on. The potential stigma of palliative care services would be important to mitigate, perhaps through psychoeducation (19, 20), and a recovery-oriented approach (21).\u003c/p\u003e\n\u003cp\u003eIncluding psychosocial care from the moment of a medical diagnosis, alongside quality indicators for psychosocial health, was considered a standard of quality cancer care (22-25).\u0026nbsp;Descriptions of clinical assessments in clinical practice documents\u0026nbsp;can better reflect the complexity of suffering by including evidence-based psychosocial interventions and clinical practice guidelines. Harnessing the strengths of multidisciplinary teams can help provide more complete patient-centered care.\u003c/p\u003e\n\u003cp\u003ePanelists also emphasized that MAiD assessments should pay systematic attention to social determinants of health.\u0026nbsp;Unmet needs such as poverty, isolation, and systemic barriers can contribute to suffering. By systematically exploring these factors, MAiD assessors and providers can ensure decisions are based on end-of-life preferences rather than social constraints. Improved health literacy and reduced stigma around palliative care could increase service acceptance, particularly among marginalized groups (26,27).\u003c/p\u003e\n\u003cp\u003eAnother recurring theme was the need for culturally responsive care, particularly in a country as diverse as Canada\u0026nbsp;(28-30). Practice documents should clearly explain how to deal with cultural beliefs and values around suffering, dying, and medical decisions making (29).\u003c/p\u003e\n\u003cp\u003eLastly, research priorities included further understanding the suffering behind MAiD requests, how patients make decisions around MAiD, and how early palliative interventions affect these decisions. Future research should investigate psychosocial interventions commonly used, care models that are culturally sensitive, and structured support for both patients and providers who are making MAiD decisions (31-33).\u003c/p\u003e\n\u003cp\u003eRecommendations from this study may help to address gaps in clinical practice documents, uphold ethical standards, and ensure patient-centered care in the MAiD context. Implementation strategies for these recommendations could include new clinical guidelines, continuing professional education, and the collection of quality metrics that assess how MAID assessors and providers address these recommendations in practice.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePotential Limitations.\u0026nbsp;\u003c/em\u003eSeveral limitations must be noted. First, virtual data collection methods may have limited participant engagement and influenced responses due to distractions and lack of verbal cues (34). Second, while diverse, the range of perspectives among stakeholders, especially on a topic such as MAiD, may have challenged consensus on certain items. Future research should consider delving deeper into the varying perspectives of clinicians, researchers, and policymakers. It should also more clearly delineate issues related to how suffering is addressed in Track 1 and Track 2 patients, as well as serve to fuel the discussion in other contexts that are likely affected by the law’s enlargement (e.g., anticipated directives, mental health, minors). Third, most stakeholder participants were from Quebec and assessing and providing MAiD in Quebec occurs under provincial as well as federal legislation. While we think that the recommendations could be equally applicable to other parts of Canada, we acknowledge that there may be regional differences to eventually consider such as variability in resource availability. There could also be restrictions in resources that are regionally available. Fourth, we strove to include a variety of stakeholders in the Delphi study, and our sample was comprised mostly of professionals and policy makers. However, it is possible that some professionals and policy makers have also had lived experience with MAiD in their personal circle. This study could eventually be repeated with a focus on people with lived experience of MAiD (patients and family members). Finally, item formulation could have impacted consensus, as some items had content that referred to combined MAiD and palliative contexts potentially influencing acceptability ratings. Further qualitative studies could clarify why certain items did not reach consensus.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe Delphi study’s conclusions offer recommendations for the content of MAiD practice guidelines and research, including content relevant to \u003cstrong\u003eearly psychosocial and palliative care interventions, considering social determinants of health, and using culturally sensitive, interdisciplinary assessments to clinical practice documents if they are not already present.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe hope that standardizing the content of practice documents will help ensure that MAiD practice is fair, ethical, and patient-focused. We recommend that MAID programs review their clinical documents and policies to identify any current gaps, and that assessors pursue specific training to address areas where they might have learning needs. Apart from the research priorities identified in this study, future research should examine how these changes are implemented and how they affect patient outcomes and quality of care.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis study was supported through a grant from the Canadian Institutes of Health Research (CIHR), the Quebec Research Network on Palliative and End of Life Care (RQSPAL), and the Centre for Research and Intervention on Suicide and End of Life Practices (CRISE).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThere are no competing interests in regards of this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and material declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets related to the current study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll authors were involved in the conceptualization, methodology, and writing/editing of the study. MH was involved in funding acquisition.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate declarations\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThis study was approved by McGill University’s Research Ethics Board.\u0026nbsp;\u003c/strong\u003eThis study adhered to the Declaration of Helsinki. \u003cstrong\u003eInformed consent was obtained from all participants.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication declaration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eGovernment of Canada. An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). 2016. Available from: https://laws-lois.justice.gc.ca/fra/LoisAnnuelles/2016_3/TexteComplet.html\u003c/li\u003e\n\u003cli\u003eDees M, Vernooij M, Dekkers W, van Weel C. 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Lancet Oncol. 2023;24(8):835-837.\u003c/li\u003e\n\u003cli\u003eB\u0026auml;uml J, Frob\u0026ouml;se T, Kraemer S, Rentrop M, Pitschel-Walz G. Psychoeducation: A basic psychotherapeutic intervention for patients with schizophrenia and their families. Schizophr Bull. 2006;32 Suppl 1\u0026ndash;9. doi: 10.1093/schbul/sbl017\u003c/li\u003e\n\u003cli\u003eChambers E, Gardiner C, Thompson J, Seymour J. Patient and carer involvement in palliative care research: An integrative qualitative evidence synthesis review. Palliat Med. 2019;33(8):969\u0026ndash;84. doi: 10.1177/0269216319858247.\u003c/li\u003e\n\u003cli\u003eMacri R, Wagner F, Stuckey MI. A values-based analysis of recovery-oriented practice in mental health care and medical assistance in dying. Can J Community Ment Health. 2020;39(2):1\u0026ndash;10. doi: 10.7870/cjcmh-2020-009.\u003c/li\u003e\n\u003cli\u003eCanadian Partnership Against Cancer, Canadian Association of Psychosocial Oncology. Pan-Canadian practice guideline: Screening, assessment, and management of psychosocial distress, depression, and anxiety in adults with cancer. 2015. Available from: https://www.capo.ca/resources/Documents/Guidelines/3APAN-~1.PDF.\u003c/li\u003e\n\u003cli\u003eJacobsen PB, Shibata D, Siegel EM, Lee JH, Fulp WJ, et al. Evaluating the quality of psychosocial care in outpatient medical oncology settings using performance indicators. Psychooncology. 2011;20(12):1221\u0026ndash;7.\u003c/li\u003e\n\u003cli\u003eCadotte T, Ismail Z, Moody L, Rugg M. Psychosocial oncology quality indicators prioritization exercise. J Clin Oncol. 2016;34(7 Suppl):277.\u003c/li\u003e\n\u003cli\u003eDerendorf L, Stock S, Simic D, Lemmen C. Developing quality indicators for cross-sectoral psycho-oncology in Germany: Combining the RAND/UCLA appropriateness method with a Delphi technique. BMC Health Serv Res. 2023;23:599.\u003c/li\u003e\n\u003cli\u003eShen MJ, Wellman JD. Evidence of palliative care stigma: The role of negative stereotypes in preventing willingness to use palliative care. Palliat Support Care. 2019;17(4):374\u0026ndash;80. doi: 10.1017/S1478951518000834.\u003c/li\u003e\n\u003cli\u003eFleary SA, Joseph PL, Gon\u0026ccedil;alves C, Somogie J, Angeles J. The relationship between health literacy and mental health attitudes and beliefs. Health Lit Res Pract. 2022;6(4):e270\u0026ndash;9. doi: 10.3928/24748307-20221018-01.\u003c/li\u003e\n\u003cli\u003eMonette EM. Cultural considerations in palliative care provision: A scoping review of Canadian literature. Palliat Med Rep. 2021;2(1):146\u0026ndash;56. doi: 10.1089/pmr.2020.0124.\u003c/li\u003e\n\u003cli\u003eGivler A, Bhatt H, Maani-Fogelman P. Culturally competent palliative care: Addressing diversity in end-of-life care. J Palliat Med. 2023;26(1):116\u0026ndash;20.\u003c/li\u003e\n\u003cli\u003eHerranz-Rubia N. Cultural competence in palliative care. Eur J Palliat Care. 2007;14(3):119\u0026ndash;22.\u003c/li\u003e\n\u003cli\u003eOczkowski SJ, Crawshaw DE, Austin P, Versluis D, Kalles-Chan G, Kekewich M, et al. How can we improve the experiences of patients and families who request medical assistance in dying? A multi-centre qualitative study. BMC Palliat Care. 2021;20(1):88. doi: 10.1186/s12904-021-00882-4.\u003c/li\u003e\n\u003cli\u003eBrown J, Goodridge D, Harrison A, Kemp J, Thorpe L, Weiler R. Medical assistance in dying: Patients\u0026apos;, families\u0026apos;, and health care providers\u0026apos; perspectives on access and care delivery. J Palliat Med. 2020;23(11):1468\u0026ndash;77. doi: 10.1089/jpm.2019.0509.\u003c/li\u003e\n\u003cli\u003eGilligan T, Coyle N, Frankel RM, Berry DL, Bohlke K, Epstein RM, et al. Patient-clinician communication: American Society of Clinical Oncology consensus guideline. J Clin Oncol. 2017;35(31):3618\u0026ndash;32. doi: 10.1200/JCO.2017.75.2311.\u003c/li\u003e\n\u003cli\u003eDonohoe H, Stellefson M, Tennant B. Advantages and limitations of the e-Delphi technique. Am J Health Educ. 2012;43(1):38\u0026ndash;46. doi: 10.1080/19325037.2012.10599216.\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 1. Sociodemographic and medical variables.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"750\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eBaseline Characteristic\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003en\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSex\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Female\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Male\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e37%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eGender\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Woman\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e34\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Man\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e37%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAge\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 20-30\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 31-40\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e15%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 41-50\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 51-60\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e24%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 61-70\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e19%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; 71-80\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e7%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eEthnicity\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Caucasian/ European\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e38\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; South Asian\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e4%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Chinese\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e6%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; No response\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e20%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eLevel of Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; College Diploma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; University Diploma\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e9%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Professional School\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e15\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e28%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Graduate Education\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e24\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e44%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; No response\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eConnection to MAiD\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Researcher\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e23\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e43%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Clinician\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e39%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Policy-Maker\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e17%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Family Caregiver\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eProvince / Territory\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Quebec\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e27\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e50%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Ontario\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e13\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e24%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; British Columbia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e19%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Saskatchewan\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Manitoba\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; Nova Scotia\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp; No response\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 33.3333%;\"\u003e\n \u003cp\u003e2%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 2. Overall overarching themes that reached consensus.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"714\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eOverarching Theme\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 1\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (Median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=46\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (Median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 3\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (Median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=54\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eIntroducing palliative and psychosocial care services early in the disease trajectory\u003c/p\u003e\n \u003cp\u003eDescription: Practice guidelines for most serious and incurable illnesses emphasize the importance of early or timely integration of palliative and psychosocial care services. There are barriers to timely integration of palliative and psychosocial care, including stigmata vis-\u0026agrave;-vis opioids, palliative care, and mental health. There may be ways to address these barriers, including psychoeducation, patient representatives, and a recovery-oriented approach.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.54 (5.00)\u003c/p\u003e\n \u003cp\u003e89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eMaintaining supportive care during the 90-day wait period until MAiD is accepted.\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;Healthcare providers have an obligation to provide ongoing care, including any indicated treatments, to patients who have requested MAID. Continuity of care may help improve suffering, which is beneficial even if the person ultimately proceeds with MAID.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.27 (4.00)\u003c/p\u003e\n \u003cp\u003e86%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eReflect complexity in the evaluation of patients with mental health comorbidities requesting MAiD.\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;Patients requesting MAiD may have underlying comorbid psychiatric illnesses that may be unidentified or undertreated by the care team. MAiD assessors and providers are in a position to identify and help manage such illnesses and ensure that alternatives to MAiD have been offered.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.26 (4.00)\u003c/p\u003e\n \u003cp\u003e84%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eSocial determinants of health need to be integrated into the evaluation of MAiD requests.\u003c/p\u003e\n \u003cp\u003eSocio-economic deprivation and other forms of structural disadvantage can contribute to suffering and may be challenging to assess and address.\u0026nbsp;Stigmatization and poor health literacy may also play a role in patients refusing palliative and psychosocial interventions. Different models need to be envisaged to increase access to care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.34 (5.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eDevelop a model for MAiD that is culturally competent.\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;Medical education is paying increasing attention to cultural competency and sensitivity to diversity. Considerations of culture and diversity may be important when evaluating how patients, caregivers, and healthcare practitioners envision life, death, suffering, and the role of medicine.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.29 (5.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eCreate a core set of standards and ensuing quality indicators for palliative care specifically in Canada to be integrated into the general monitoring system for end-of-life care.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;There is a need to develop standards and quality indicators for palliative care in Canada, allowing the country to initiate palliative care quality improvement and monitor quality end-of-life care. These indicators would be used throughout the provision of care in all major disease trajectories (e.g., cancer, cardiovascular, neurodegenerative disease). A core set of quality indicators would constitute standards for palliative care that are enforced through Accreditation Canada. These indicators are needed in all places where people receive care for chronic life-threatening illnesses, and need to be assessed again at the time of MAiD requests and can serve to inform care options provided or offered during MAiD assessments.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.24 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eOffer supportive care for people suffering from non-life-threatening conditions.\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;Additional safeguards are needed for patients whose deaths are not reasonably foreseeable, such as consultation of physicians specializing in the disease being treated, a 90-day assessment period, and access to supportive care\u0026nbsp;addressing physical, psychological and existential symptoms with practical support.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.13 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eOffer interventions based on hope, dignity, and maintaining a sense of autonomy/control.\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;MAiD requests are often based on existential distress and a loss of a sense of control and autonomy. Interventions focused on these threats may help improve their suffering, whether they chose to proceed with MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e3.97 (4.00)\u003c/p\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.18 (4.00)\u003c/p\u003e\n \u003cp\u003e77%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eImplementing an interdisciplinary approach to the care of a patient requesting MAiD.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;The suffering that motivates MAiD requests is due to a combination of physical, psychological, practical/social, and existential issues. Considering the nature of suffering in MAiD, there may be a benefit to integrating an interdisciplinary approach in assessment and management of MAiD requests, including palliative care, psychiatrists, psychologists, social workers, nurse\u0026nbsp;practitioners, physiotherapists, occupational therapists, and spiritual counselors. Continuity of care is a priority.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.24 (5.00)\u003c/p\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eNormalize palliative care as part of health care to help destigmatize it.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;The stigma surrounding palliative care may prevent individuals from utilizing palliative care themselves or from enrolling family members. A public health strategy with media campaigns designed to educate the public on palliative care in a way that associates it with life and promotes hopefulness may be helpful in overcoming this stigma.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eConsider the effect of MAiD on healthcare provider burnout and emotional and psychological distress.\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;Burnout in healthcare professionals has been increasing, especially following the onset of the COVID-19 pandemic. In the context of MAiD, healthcare providers can sometimes face challenges navigating patients\u0026rsquo; requests and adapting to changes in Canada\u0026rsquo;s MAiD legislation. Providers may experience distress because of participating in MAiD assessment and provision, or as a result of being prevented from participating in MAiD assessment and provision (either through institutional policies or other means). Both participation and non-participation may conflict with a provider\u0026rsquo;s values and beliefs. There is a need to ensure that healthcare providers are supported regardless of their involvement in MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e3.95 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e3.90 (4.00)\u003c/p\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e4.02 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 55.5245%;\"\u003e\n \u003cp\u003eCreate a core set of existential / psychosocial indicators to be integrated into the monitoring system for end-of-life care.\u0026nbsp;\u003c/p\u003e\n \u003cp\u003eDescription:\u0026nbsp;\u0026nbsp;According to the Annual Report on MAiD in Canada, MAiD requests are motivated principally by existential and psychological distress.\u0026nbsp;There are validated measures of psychological and existential distress available, and some interventions may be effective to address this distress. Included in palliative care indicators, it would be important to develop a core set of psychosocial care quality indicators.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e70%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.5455%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 15.3846%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eTable 3. Changes to guiding MAiD clinical practice documents at a policy level that reached consensus to guide clinical care.\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"726\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItems\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eOffer psychosocial care for identified distress as early as the onset of diagnosis and at crucial times during the disease trajectory.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.45 (5.00)\u003c/p\u003e\n \u003cp\u003e92%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eConsider and discuss a palliative approach as early as the onset of diagnosis.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.34 (4.50)\u003c/p\u003e\n \u003cp\u003e89%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate follow-up and support for patients found to be ineligible for MAID at the time of the assessment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.26 (4.00)\u003c/p\u003e\n \u003cp\u003e84%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eAddress stigma towards mental health in patients requesting MAiD.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.21(4.00)\u003c/p\u003e\n \u003cp\u003e84%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate standards and quality indicators for palliative care specifically in Canada.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.24 (4.00)\u003c/p\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate a core set of existential / psychosocial care quality indicators in Canada.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.97 (4.00)\u003c/p\u003e\n \u003cp\u003e81%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eInclude a basic psychosocial needs assessment within the context of a MAiD request, considering both patient and family needs.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.24 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eInvolve a social worker and other psychosocial professionals when the MAiD evaluation reveals that social determinants of health are a significant component of suffering.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.24 (4.50)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eClarify bio-psycho-social-existential issues associated with intolerable suffering (including social determinants of health) in patients requesting MAiD in the context of life-threatening and non-life-threatening conditions.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.21 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eMention interventions that may be effective to address existential and psychosocial distress in a patient requesting MAID.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.18 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eReinforce the importance of providing or continuing support for patients and caregivers during the 90-day wait period for MAiD acceptance via community resources and psychological assistance.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.13 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eInclude a core set of brief validated measures for psychological, practical/social, and existential distress for MAID assessors to use in their evaluation of MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.79 (4.00)\u003c/p\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.00 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eUnderscore the importance of identifying those who would be at risk of suicide if deemed ineligible for MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.79 (4.00)\u003c/p\u003e\n \u003cp\u003e61%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e77%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eImplement explanations related to shared decision-making and advanced directives for MAiD requestors as a means to foster a sense of control and autonomy.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.90 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.03 (4.00)\u003c/p\u003e\n \u003cp\u003e77%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate the evaluation of social determinants of health as part of a MAiD assessment.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.21 (4.00)\u003c/p\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eOutline the various treatment options (pharmacologic, psychotherapy) available for psychiatric illness and psychological distress in patients requesting MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.18 (4.50)\u003c/p\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eEvaluate suicidality, and whether suicidality may be affecting a wish to hasten death in patients requesting MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.05 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eRefer to educational curriculum venues for MAiD assessors and providers that comprehensively covers evaluating and addressing suffering in patients requesting MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.03 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eAddress issues of cultural competency and sensitivity to diversity in addressing how patients, caregivers, and healthcare practitioners envision life, death, suffering, and the role of medicine in the context of a MAiD request.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.13 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate diagnostic tools to evaluate mental health comorbidities in patients requesting MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.95 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate strategies to prevent and manage MAiD healthcare provider burnout, such as providing organizational and mental health support.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.00 (4.00)\u003c/p\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e4.04 (4.00)\u003c/p\u003e\n \u003cp\u003e73%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eEstablish clear roles, responsibilities, and clinical pathways for each member of the interdisciplinary care team to assess and address suffering in MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.03 (4.50)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.08 (4.50)\u003c/p\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate current evidence-based palliative and supportive care guidelines for management of symptoms and distress into the process of MAiD assessment and provision.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.97 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.97 (4.00)\u003c/p\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eEstablish care models that could be used when resources are lacking to address unbearable suffering in the context of MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.13 (4.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate an evaluation of unmet needs related to social determinants of health underlying unbearable suffering in MAiD requests and indicate whether treatment and therapies exist and are available to the patient, at the hospital and community levels.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e4.18 (5.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eInclude dignity measures and exploration of patients\u0026rsquo; suffering during MAiD evaluations.\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e4.00 (4.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.1625%;\"\u003e\n \u003cp\u003eIntegrate the systematic evaluation of depression and suicidal ideation in the assessment of MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3251%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.1873%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\u003cp\u003eTable 4. Research priorities that reached consensus.\u0026nbsp;\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"727\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eItems\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 1\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=46\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 2\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=53\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRound 3\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eMean (median)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e%\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003en=54\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand the perspectives of patients with respect to different forms of suffering, their influence on MAiD requests, and how they change over the course of the MAiD trajectory (psychological, practical/social, existential, physical).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.47 (5.00)\u003c/p\u003e\n \u003cp\u003e95%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eIdentify how mental health stigma affect the provision of optimal care in the context of MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.21 (4.00)\u003c/p\u003e\n \u003cp\u003e87%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eDetermine the impact of an early/timely palliative approach on requests for MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.21 (4.00)\u003c/p\u003e\n \u003cp\u003e85%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand what triggers a patient to delay MAiD or change their mind about MAiD following a request.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.87 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e82%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand how doctor-patient communication best practices are applied to conversations around suffering within a MAiD request.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.73 (4.00)\u003c/p\u003e\n \u003cp\u003e65%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.23 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand the influence of cultural factors on MAiD requests, use of palliative care services, and the assessment of suffering.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.16 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eDevelop effective, scalable, and acceptable treatments for existential and psychosocial distress in the context of MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.05 (4.00)\u003c/p\u003e\n \u003cp\u003e79%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand the impact of social and cultural factors on the interpretation of suffering from the perspective of patients, families, and healthcare practitioners when MAiD is requested.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand suffering in the context of MAiD requests associated with non-life-threatening conditions and how this suffering changes with time.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eDevelop an educational curriculum for MAiD assessors and providers that comprehensively covers evaluating and addressing suffering.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.05 (4.00)\u003c/p\u003e\n \u003cp\u003e76%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand MAiD assessors\u0026rsquo; and providers\u0026rsquo; knowledge and skills in regard to complex assessments of suffering within MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.05 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eEngage national leaders and stakeholders to develop and enact a public health strategy on palliative care.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.03 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.10 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand the relative contribution of social determinants of health to suffering underlying track 1 versus track 2 MAiD requests.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.05 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand health service utilization when patients are found ineligible for MAID,\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.79 (4.00)\u003c/p\u003e\n \u003cp\u003e63%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.05 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eEvaluate the effect of treating underlying psychiatric illness on suffering reported by people requesting MAiD.\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.03 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eDevelop a core set of validated quality indicators for existential / psychosocial care in Canada to be integrated into the MAiD monitoring system through Health Canada and the Canadian Institute of Health Information.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.79 (4.00)\u003c/p\u003e\n \u003cp\u003e61%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand the perspectives of MAiD clinicians with respect to different forms of suffering, their influence on MAiD requests, and how they change over the course of the MAiD trajectory (psychological, practical/social, existential, physical).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.89 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand the perspectives of family caregivers with respect to different forms of suffering, their influence on MAiD requests, and how they change over the course of the MAiD trajectory (psychological, practical/social, existential, physical).\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.84 (4.00)\u003c/p\u003e\n \u003cp\u003e74%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand burnout in MAiD assessors and providers, how suffering is addressed, and the impact on clinical practice.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.84 (4.00)\u003c/p\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.82 (4.00)\u003c/p\u003e\n \u003cp\u003e67%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.94 (4.00)\u003c/p\u003e\n \u003cp\u003e73%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eBetter understand the impact of early conversations around MAiD on a sense of control and the eventual.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.81 (4.00)\u003c/p\u003e\n \u003cp\u003e59%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.85 (4.00)\u003c/p\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.96 (4.00)\u003c/p\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eDevelop and evaluate a model of care that emphasizes support throughout the 90-day wait period for people requesting MAiD by track 2.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.84 (4.00)\u003c/p\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.95 (4.00)\u003c/p\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand how hope and hopelessness are addressed in patients requesting MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.86 (4.00)\u003c/p\u003e\n \u003cp\u003e68%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.95 (4.00)\u003c/p\u003e\n \u003cp\u003e72%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eDetermine the impact of early and timely psychosocial care on requests for MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e4.08 (4.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eCharacterize how the nature of suffering in the context of MAiD requests associated with non-life-threatening conditions may be different from that of MAiD requests associated with a life-threatening condition.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.92 (4.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e--\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 57.0839%;\"\u003e\n \u003cp\u003eUnderstand the extent to which knowledge of certain care processes (e.g., advanced directives, palliative sedation) provide patients with a sense of control and change their minds as to MAiD.\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.76 (4.00)\u003c/p\u003e\n \u003cp\u003e66%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.79 (4.00)\u003c/p\u003e\n \u003cp\u003e69%\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 14.3054%;\"\u003e\n \u003cp\u003e3.86 (4.00)\u003c/p\u003e\n \u003cp\u003e71%\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cancer, Oncology, Canada, Delphi Technique, Guidelines, Psychosocial Care, Palliative Care, Medical Assistance in Dying","lastPublishedDoi":"10.21203/rs.3.rs-8206322/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8206322/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eObjective:\u003c/strong\u003e Standardized protocols for assessing and addressing patient suffering are absent from Canadian clinical practice documents on medical assistance in dying (MAiD). Our Delphi study aimed to seek expert consensus on potential improvements to clinical practice documents and on research priorities to address suffering in MAiD.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e A multidisciplinary panel of 54 experts from across Canada participated in a modified e-Delphi study. Three rounds of surveys were conducted after a national knowledge dissemination meeting.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults:\u003c/strong\u003e There was agreement on 27 clinical practice document revisions and on 24 research priorities. Among the main recommendations were early integration of psychosocial and palliative care, \u003cstrong\u003eproviding follow-up and support for patients deemed ineligible for MAiD, addressing mental health stigma, including basic psychosocial assessments in MAiD evaluations, involving social workers when suffering of MAiD requestors is linked to social determinants of health\u003c/strong\u003e, and clarifying bio-psycho-social-existential issues associated with intolerable suffering (including social determinants of health) in patients requesting MAiD in the context of life-threatening and non-life-threatening conditions.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e Our results provide practical recommendations for improving MAiD clinical practice documents as they pertain to suffering, as well as identify research priorities to pursue. Our experience can inform clinical policies in Canada and other countries where MAiD is legal or being considered.\u003c/p\u003e","manuscriptTitle":"Medical Assistance in Dying in Canada: A Multidisciplinary Pan-Canadian Delphi Study to Inform Clinical Practice Documents and Plan a Research Agendas","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-06 17:15:14","doi":"10.21203/rs.3.rs-8206322/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-01-26T14:33:22+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-17T04:26:33+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-15T12:54:16+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"97030658588698967515013435964163285177","date":"2026-01-05T07:10:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"94145703377884352423499904212212491106","date":"2026-01-04T18:32:49+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"104665340431120579780747085129110861147","date":"2026-01-04T16:27:05+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-04T16:15:26+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-04T16:04:45+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-22T05:16:54+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-17T18:14:57+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Palliative Care","date":"2025-12-17T17:41:18+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-palliative-care","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"pcar","sideBox":"Learn more about [BMC Palliative Care](http://bmcpalliatcare.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/pcar/default.aspx","title":"BMC Palliative Care","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7be5196d-af98-4f8d-bb24-3a23704b62be","owner":[],"postedDate":"January 6th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-28T17:08:14+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-06 17:15:14","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8206322","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8206322","identity":"rs-8206322","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}