Medical assistance in dying in pediatrics: a retrospective case study of clinical interactions and implications for team training

Abstract

Objectives

In Canada, medical assistance in dying (MAiD) has been a legal end-of-life (EOL) option since 2016. Although minors are not legally eligible, pediatric palliative care (PPC) teams can be involved in MAiD-related discussions initiated by patients or parents. However, little is known about how these discussions unfold in pediatrics. This study sought to describe the structure and content of these interactions, with the aim of developing a typology and clinical vignettes to support the preparation and training of pediatric healthcare professionals.

Methods

We conducted a retrospective and descriptive case study within a single PPC service in a Canadian pediatric academic tertiary hospital. Data were collected from patient's charts (September 2013 to August 2023), including patient demographics, clinical characteristics, palliative care involvement, MAiD-related discussions and EOL details (N = 11). Descriptive statistics, as well as thematic and comprehensive analyses were used.

Results

We identified 11 cases of documented MAiD-related interactions involving patients aged <1 to 18 years. Most interactions were initiated by patients' parents (73%; n = 8), and some by patients themselves (27%; n = 3). We identified three types of MAiD-related interactions: implicit (n = 2), explicit exploratory (n = 5) and explicit direct (n = 4). Based on this typology, we co-developed six clinical vignettes to illustrate these scenarios.

Conclusion

Although rare, MAiD-related interactions in pediatric settings are complex and high-stakes, underscoring the need for enhanced training of pediatric healthcare professionals. The proposed typology and vignettes provide a framework to support reflective ethical practice and enhance pediatric teams' preparedness for EOL beyond the specific clinical and legal context of our study.

Introduction

Medical Assistance in Dying (MAiD) was decriminalized in Canada in 2016, which allowed physicians and nurse practitioners to prescribe, provide or administer substances to an eligible person, at their request, to end their life (1). While federal legislation sets the legal framework, provinces may adopt more restrictive laws. Quebec is the only province that has done so, with its Act respecting end-of-life care, which defines MAiD as a “care consisting in the administration by a competent professional of medications or substances to a patient, at the patient's request, in order to relieve their suffering by hastening death” (2). This Act includes strict eligibility criteria, notably the requirement that individuals be at least 18 years old and personally make the request (Table 1) (3).

Table 1.

Eligibility criteria for obtaining MAiD in Québec (April 2025).

1. Being covered by Québec Health Insurance Act

2. Being at least 18 years of age

3. Being capable of giving consent to care, which means the person must be able to understand the situation and the information given by health professionals as well as make decisions

4. Suffering from a serious, incurable illness

5. Being in an advanced state of irreversible decline in capability

6. Experiencing constant and unbearable physical or psychological suffering that cannot be relieved in a manner the person deems tolerable.

Currently, only the Netherlands, Belgium, and Colombia authorize euthanasia for minors under strict conditions (4). No cases have been reported in Colombia and only a few in the Netherlands and Belgium, with limited information available about the circumstances of these requests (4,5). In Canada, extending MAiD to mature minors is the subject of ongoing debates. Some experts argue that age alone should not determine decision-making capacity and recommend extending the criteria to include mature minors, particularly when their natural death is reasonably foreseeable (6,7). In Quebec, the mature minor doctrine is not recognized; consent is tied to specific age thresholds, with minors aged 14 and older allowed to make certain health-related decisions (8–10). This age-based consent framework poses legal and ethical challenges for extending MAiD to minors.

Even if MAiD for minors is not legal in Canada, pediatric palliative care (PPC) practitioners are already facing questions and conversations regarding MAiD (11). Some critically ill patients, due to the complexity of their conditions and the need for continuity of care, remain under pediatric care after reaching the age of majority and may then become legally eligible for MAiD. For example, between 2000 and 2020, a PPC team cared for 910 patients aged 1 to 24 years old (12), some of whom meet the age requirement for MAiD. Thus, pediatric health care providers (HPs) must be prepared to engage in MAiD discussions, provide information, and potentially participate in MAiD assessment or provision. This responsibility is heightened by advances in medicine which contribute to the prolonged survival of children with complex chronic conditions (13,14).

In 2018, the Canadian Paediatric Society survey found that some minors had explicitly requested MAiD, and that such requests were more frequently made by parents (10,15). A recent study in Quebec also confirmed that in some cases, adolescents express a desire to consider MAiD (16). Despite this, there is little empirical data on how MAiD is addressed in pediatric settings, how it is understood by minors and families, and what kind of training and support HPs need to engage in these complex, rare, and high-stakes conversations (17).

This study explores how MAiD-related interactions unfold within a PPC team in a tertiary pediatric hospital in Quebec, with three objectives: (1) Describe the characteristics of cases involving MAiD-related interactions between the PPC team and patients or parents, including the illness trajectory and end-of-life (EOL) pathways in which these interactions occur; (2) Analyze and categorize these interactions to develop an original typology that enhances understanding of their dynamics, nature, and complexity; and (3) Develop clinical vignettes to illustrate key concepts emerging from the study findings and support the training of pediatric HPs. We chose the term “interactions” to include explicit requests, specific questions, and broader conversations about MAiD.

Methods

Design and setting

This retrospective and descriptive case study was conducted within a PPC service at the Sainte-Justine University Hospital Center (SJUHC), a tertiary care pediatric center in Montreal, Quebec, Canada. It covers a 10-year period (September 1, 2013 to August 31, 2023).

Collection

The PPC service had no standardized MAiD documentation form, and most notes were handwritten for clinical rather than research purposes, making keyword-based searches unfeasible, a common limitation in retrospective studies involving emerging or rare cases (18). To address these constraints without relying solely on recall, we adopted a three-step process for case selection:

• Step 1—Identification: potential cases (n = 14) were identified through the PPC team's collective memory, stimulated by reviewing patient lists (year of follow-up, age, gender, diagnosis). Recollection served only to locate potential cases.

• Step 2—Verification: each potential case was systematically verified in the medical record. Cases without a specific note documenting a MAiD-related interaction were excluded (n = 3).

• Step 3—Final selection: the remaining cases with confirmed documentation (n = 11) were retained after a final verification with the team. Medical records were the sole data source.

Inclusion required both recollection and confirmation through rigorous chart verification, representing an initial step toward establishing systematic knowledge on MAiD-related interactions in PPC.

Data were extracted using a four-step triangulation process designed to support the completeness and reliability of key data elements (19–21): (1) gathering of all available electronic and printed documents from patient files and clinical notes; (2) development of a structured extraction form including variables adapted from adult MAiD studies (22–27) and reviewed by all team members (Table 2); (3) data extraction by MM in collaboration with the PPC team to ensure consistent interpretation of clinical wording and key terms; (4) revision of all cases based on team members' recall for confirmation.

Table 2.

Data collection form.

Categories	Variables	Codes
Medical record	Number	—
Basic demographic data	Age* (at the first MAiD interaction)	<1; 1 to 5; 6 to 13; 14 to 17; 18; >18
	Sex	1 = male; 2 = female
	Family profile	Parental status: 1 = married or common-law partners; 2 = separated/divorced Siblings: 0, 1, 2, 3.
Illness and palliative care involvement	Primary diagnosis	Ex: acute lymphoblastic leukemia
	Primary diagnosis category	1 = oncology; 2 = genetics; 3 = metabolic; 4 = neurological/neurodegenerative; 5 = other
	Main reason for PPC referral	1 = patient and/or parent support; 2 = discussion regarding goals of care; 3 = caregiver support; 4 = assistance with symptom management
	Primary specialty of the referring professional	1 = general pediatrics; 2 = hematology-oncology; 3 = pediatric intensive care; 4 = genetics; 5 = others
Information related to the interactions about MAiD	Initiator of the interaction	1 = patient; 2 = parents; 3 = others
	Palliative care practitioner(s) present during the interaction	1 = PPC team member alone; 2 = PPC team (2 or more members; 3 = interdisciplinary meeting (PPC team and other HPs)
	Type of MAiD discussion	1 = request for MAiD; 2 = request for information about MAiD; 3 = other discussion
	Location of the first interaction	1 = outpatient follow-up; 2 = hospital; 3 = long-term care facility
	Illness trajectory at time of first interaction	1 = gradual decline; 2 = episode of acute deterioration 3 = end-of-life phase; 4 = other
	Motivations for initiating interaction (emerging descriptive codes from data collection process, not mutually exclusive)	Patient suffering: physical pain Patient suffering: psychological distress Patient suffering: existential distress Decreased quality of life Loss: autonomy Loss: dignity Loss: interaction Anticipation and control: fear of future suffering Anticipation and control: specific fear of dying by choking Poor prognosis: Failure of curative treatments Poor prognosis: Irreversibility of condition EOL symptoms: physical signs of EOL/body deterioration EOL symptoms: Perception of meaningless EOL/unnecessary suffering Wish to honor child's prior expressions: Past expression of child's desire for MAiD Wish to honor child's prior expressions: Past expression of child's will to die
	Therapeutic options offered	1 = classic symptom management; 2 = discontinuation of nutrition and hydration with symptom management; 3 = continuous palliative sedation; 4 = support in MAiD request
Information related to death (if applicable)	Death	1 = yes; 2 = no
	Location of death	1 = hospital; 2 = home: 3 = PPC home
	End of life care received	1 = standard symptom management; 2 = discontinuation of nutrition and hydration with symptom management; 3 = continuous palliative sedation; 4 = MAiD
Dates	Birth	YYYY-MM-DD
	Diagnosis	YYYY-MM-DD
	First PPC evaluation	YYYY-MM-DD
	First interaction about MAiD	YYYY-MM-DD
	Death (if applicable).	YYYY-MM-DD
Other relevant information	Involvement of other services and professionals	1 = clinical ethics unit; 2 = pediatrician; 3 = child psychiatrist; 4 = social worker; 5 = other

^*Age categories were created based on existing literature in pediatrics and the legal context in Quebec, where minors aged 14 to 17 are permitted to make health-related decisions on their own (9,28,29). The defined age groups are: infant (<1), preschoolers (1 to 5 years), school-age children (6 to 13 years), adolescents (14–17) and young adults (≥18 years).

Analysis

All data were anonymized and assigned unique identifiers. The quantitative data were imported into SPSS for analysis. Descriptive statistics (frequencies, means) were used to characterize each case (30). Qualitative data extracted from medical records using the structured data extraction tool underwent an inductive descriptive-interpretative thematic analysis. This analysis aimed to organize extracted content into a comprehensive analytic structure, enabling the categorization of motivations for and types of MAiD-related interactions. These categories ultimately supported the development of a data-driven typology of MAiD-related interactions. Three analysts (MM, MAM, AS) coded the data and discussed discrepancies to achieve consensus, with input from CJB to refine definitions and stabilize the coding structure.

Based on this typology, clinical vignettes were developed through a multi-step process informed by vignette methodology literature emphasizing their value for translating empirical findings into practice-relevant scenarios while preserving confidentiality (31). First, initial drafts were prepared by MM based on selected patient files to ensure grounding in real clinical encounters (24). Second, drafts were reviewed and modified collaboratively with the PPC team by replacing identifiable details with equivalent hypothetical characteristics to safeguard anonymity while preserving clinical relevance (32). Finally, all authors reviewed the final versions to ensure empirical authenticity, conceptual coherence, and educational utility.

Reflexivity and positionality

The research team was interdisciplinary, with expertise in PPC medicine, nursing, psychology, ethics, sociology, and education. This diversity, combined with the involvement of both clinical and nonclinical analysts, as well as members and nonmembers of the PPC team, enabled a multidimensional understanding of the research problem and actively mitigate potential interpretive biases through collective analytic discussions (33).

Results

Characteristics of cases involving MAiD-related interactions

Over the study period (September 1, 2013 to August 31, 2023), 11 documented cases of MAiD-related interactions occurred between patients/parents and the PPC team. Eight were initiated by parents of children who lacked the capacity to consent or who had become incapacitated (aged <1 to 18), and three by patients (one 11-year-old and two young adults). No discussions were initiated by the PPC team.

Characteristics of patients

Oncologic (n = 4, 36%) and genetic conditions (n = 3, 27%) were the most common diagnoses, followed by metabolic (n = 2, 18%) and neurological/neurodegenerative conditions (n = 2, 18%). Most families were composed of married or common-law parents (n = 7, 64%) and most patients (n = 8, 73%) had at least one sibling (Supplementary table S1).

Motivations for initiating MAiD-related interactions

The three patients who initiated MAiD-related interactions were primarily motivated by psychological distress and fear of future suffering. For the eight parents, the most common reason was the perceived futility of interventions causing unnecessary suffering in the EOL context (n = 6), followed by physical pain (n = 4) and the irreversibility of their child's condition (n = 4). These motivations were not mutually exclusive; in some cases, several were cited simultaneously. Additional motivations and details are presented in Table 3.

Table 3.

Main motivations for initiating MAiD-related interactions (N = 11).

Main motivations		Interactions initiated by patients n = 3	Interactions initiated by parents n = 8
Patient suffering	Physical pain	2 (67%)	4 (50%)
	Psychological distress	3 (100%)	—
	Existential distress	1 (33%)	—
Decreased quality of life		1 (33%)	3 (37%)
Loss	Autonomy	2 (67%)	—
	Dignity	2 (67%)	—
	Interaction	1 (33%)	2 (25%)
Anticipation and control	Fear of future suffering	3 (100%)	3 (37%)
	Specific fear of dying by chocking	1 (33%)	1 (12%)
Poor prognosis	Failure of curative treatments	—	1 (12%)
	Irreversibility of condition	—	4 (50%)
End-of-life (EOL) symptoms	Physical signs of EOL/body deterioration	—	3 (37%)
	Perception of meaningless EOL/unnecessary suffering	—	6 (75%)
Wish to honor child's prior expressions	Past expression of child's desire for MAiD	—	1 (12%)
	Past expression of child's will to die	—	1 (12%)

Contexts of MAiD-related interactions

MAiD-related interactions occurred mostly during inpatient care (n = 5, 45.4%) or outpatient follow-up (n = 5, 45.5%), with one case in a long-term care setting. In four instances (36.4%), the entire PPC team was present during the first MAiD-related interaction, and in another four (36.4%), a single member engaged in the interaction (nurse or physician). Two interactions (18.2%) occurred during interdisciplinary meetings (PPC team and other HPs), and one involved a PPC nurse alongside a non-PPC attending physician.

Over half of the cases (n = 6, 54.6%) occurred during the EOL phase of the patient, with others during acute deterioration (n = 2, 18.2%) or gradual decline (n = 3, 27.3%). Among the EOL cases, two (18.2%) occurred after the discontinuation of life-prolonging measures (8 and 18 days between the first interaction and death). MAiD-related interactions could occur as early as the first day of PPC team involvement, with the median time between first PPC team contact and first MAiD-related interaction being approximately one year (range = 0 days to ∼3 years) (Supplementary Figure S1).

Death outcomes

At the time of the study, 9 of the 11 patients had died, with a median time of 23 days (range: 2 to 81 days) between the first MAiD-related interaction and death (Supplementary Figure S1). Six deaths occurred in the hospital (86%) following MAiD-related interactions initiated by parents. Three deaths occurred outside of the hospital setting: one occurred at home following a patient-initiated MAiD interaction, and two occurred in a PPC home (a pediatric hospice residence, distinct from an adult hospice), one of which was initiated by a patient and the other by parents. Among the two survivors, one remained under PPC care, while the other had transitioned to adult palliative care through a close collaboration ensuring a needs-based transition. Regarding EOL care, three patients died following classic symptom management, three after the discontinuation of artificial nutrition and hydration, two with continuous palliative sedation and one patient received MAiD upon reaching the legal age of 18.

MAiD case involvement in a pediatric context

The first documented MAiD-related interaction of the patient who received MAiD occurred 18 months after the initial PPC involvement. MAiD was ultimately administered by an authorized physician nearly 3 months later with the involvement of the parents. The process was coordinated through the hospital's interdisciplinary support group (ISG) for MAiD, which comprises the entirely PPC team and other institutional stakeholders, including clinical ethicists, professionals involved in staff support and well-being, pharmacists and administrative representatives. As an unprecedented situation within the pediatric setting, this case required the activation of the ISG, which sought guidance and collaboration with adult hospital MAiD coordinators and assessors to clarify the current legal framework and the full MAiD process, and led to the development of institutional protocols for MAiD procedures and documentation. Eligibility was confirmed by two independent physicians (one pediatrician and one physician with adult MAiD assessment expertise), and a child psychiatrist was involved for complementary evaluation. The PPC team, together with the patient's pediatrician and social worker, provided continuous support to the patient and family throughout. Staff concerns, as well as the emotional and moral impact, were addressed through the ISG, which provided structured spaces for individual and group preparation, discussion, and debriefing.

Typology of MAiD-related interactions and illustrative vignettes

Two main types of MAiD-related interactions between the PPC team and parents or patients were identified:

1. Implicit interactions: expressions of suffering or EOL wishes that do not explicitly mention MAiD.

2. Explicit interactions: clear references to MAiD in two forms:

   • Exploratory: mention or request for information or clarification about MAiD.

   • Direct: specific request for MAiD.

As illustrated in Figure 1, only 2 of the 11 cases were implicit (18%), one involving a patient expressing a desire to die and another involving parents wanting to explore all EOL options. The remaining 9 cases were explicit (82%), divided into exploratory (5 cases, 45%) and direct requests (4 cases, 36%).

Figure 1.

Number of MAiD-related interactions with the pediatric palliative care (PPC) team, by patient age at the time of the interaction, initiator of the interaction (parent or patient), and type of interaction (implicit, explicit exploratory, explicit direct).

To illustrate these types and subtypes of MAiD-related interactions, particularly regarding the initiator, we developed six vignettes (Table 4).

Table 4.

Vignettes illustrating types and subtypes of MAiD-related interactions, based on the initiator of the interaction.

Type of MAiD-related interaction	Patient	Parents
Implicit	Loic is an 11-year-old boy diagnosed a year ago with a life-threatening tumor, for which no cure is currently available. He is followed by the PPC team since his diagnosis, receiving support in making goal-concordant decisions as well as symptom management. Given the progression of his disease and his prognosis, Loic expresses repeatedly, to his family and the care team, a desire to end his life. Caregivers and clinicians alike note his remarkable maturity despite his young age. During a follow-up meeting, Loic asks the PPC team for help to “go to heaven”, as he feels ready to “reunite with his grandparents”.	Kevin is a 1-year-old baby who has been followed by the PPC team for about 3 months due to a serious, life-threatening mitochondrial disease for which no curative treatment is available. His neurological condition is deteriorating he has been experiencing more seizures and increased dysphagia recently, causing significant distress to his parents. During a follow-up meeting with the PPC team, his parents relay an increasing fear for Kevin's future, asking questions about possible end-of-life scenarios for him (what is possible now? How? When?). As the disease progresses, the PPC team tries to answer questions and provide support as best they can.
Explicit/Exploratory discussions	Victor is an 18-year-old young man living with his parents. He is living with a neurodegenerative disease that has progressed slowly over the course of the last decade. During a follow-up meeting with the PPC team (physician and nurse), he expresses his desire to learn more about MAiD. The team explains what this implies and explores what prompted his desire to know more about MAiD.	Andrea is six months old and diagnosed with a severe, congenital intestinal disorder that causes intractable pain with any oral feeding. After several unsuccessful pharmacological trials, her parents and clinicians make the difficult decision to discontinue artificial nutrition and hydration. As Andrea progresses through the end of her life, her parents find the wait increasingly unbearable, especially now that her death is foreseeable, and she is irreversibly unconscious. During an interdisciplinary meeting, they ask whether MAiD might be an option for Andrea.
Explicit/Direct discussions and requests	At a second follow-up meeting, Victor reiterated his desire to submit a MAiD request. At this point, the team gives a more in-depth explanation of the steps involved in the care process. They suggest that he reflects on the following questions: What does he understand about his disease and prognosis? What quality of life does he consider acceptable? Why does he wish to receive MAiD?	Clara is 15 years old and has terminal acute lymphoblastic leukemia. During a visit of the PPC physician to her hospital room, she is confused and disoriented. Her parents requested that she receive MAiD, relaying that a few weeks before she had expressed her wish to die if no cure was possible. The physician explains that their daughter does not meet the criteria for MAiD under the current legal framework, being under 18 years of age and being unable to provide informed consent. However, the physician discusses all options available to ensure her comfort and alleviate suffering at the end of her life.

Discussion

This study documents 11 cases of MAiD-related interactions over a decade within a PPC team at a tertiary pediatric hospital in Quebec. This setting constitutes a distinctive clinical and legal context, as Quebec is the only Canadian province with its own MAiD legal framework and reports among the highest proportions of adult deaths attributable to MAiD in Canada and globally (7.9%) (34). This context offers a unique clinical environment and a valuable early indicator of emerging MAiD-related interactions in pediatric care. To our knowledge, it is the first empirical study detailing such interactions in a pediatric context, involving patients ranging from under 1 year to just over 18 years. The presence of a legal MAiD case—where a patient followed by a PPC team became eligible upon reaching the age of majority and subsequently received MAiD from an authorized physician with active PPC team involvement-, illustrates the expanding scope of PPC responsibilities and highlights the need for training and institutional preparedness.

By describing and characterizing MAiD-related interactions in PPC, we found that they occur in diverse and unpredictable contexts, influenced by the initiator, motivations, patient's age and condition, and the illness trajectory. Approximately three-quarters of the interactions were initiated by parents, consistent with previous findings (6,10,15). Parent's motivations often stemmed from EOL symptoms, including physically deterioration and a perceived lack of meaning, which they associated with unnecessary suffering. In some cases, these discussions occurred after a decision to discontinue life-sustaining treatments, reflecting motivations similar to those underlying treatment limitation decisions (35,36). In contrast, patients were primarily motivated by suffering and a desire to maintain control, aligning with motivations seen in adults (23,34).

None of these interactions were initiated by the PPC team, consistent with guidance that pediatric providers should not initiate MAiD discussions (37). By contrast, in adult care, clinicians may, when legal and clinically appropriate, introduce MAiD as a clinical care option to support informed consent and respect for patient autonomy (38–40). This raises ethical questions about the appropriateness and timing of initiating such discussions with patients nearing adulthood who meet all other MAiD eligibility criteria except age, and how to balance the obligation to provide essential information, respect for autonomy, and protect vulnerable patients.

The case of the 18-year-old patient who received MAiD with continuous support and involvement from the PPC team highlighted gaps in clinical and institutional preparedness, revealing an ethical tension between the current legal framework and the clinical realities faced by pediatric teams. It also raised clinical and organizational challenges, including ensuring continued PPC involvement at EOL, supporting professionals' competencies, addressing moral distress, and managing MAiD practices in an environment primarily focused on caring for pediatric patients.

Preparing pediatric teams for emerging MAiD-related interactions is crucial. While still rare, these interactions are rising. The increasing integration of MAiD into adult EOL care in Quebec (34) may reflect growing social familiarity and acceptability, encouraging more families, and potentially minors, to raise the topic. This normalization underscores the urgent need for reflection and timely preparation of PPC teams and other pediatric HPs likely to be involved, such as oncology services or transitions programs. Whatever their form, these interactions often reflect a real need for emotional support and clarity, requiring sensitive responses (11).

Healthcare institutions also have an ethical responsibility to recognize and support the role of PPC teams, both in their direct clinical involvement and in their broader contribution to institutional responses to MAiD-related situations. Despite their expertise in EOL care, most have little or no direct experience with MAiD assessment or provision and limited access to current information, underscoring the need for access to training and mentorship to ensure the safety and quality of care. Our results illustrate how structured institutional mechanisms, -such as ISGs, well established in adult care in Quebec-, can also provide a framework for coordination, support, and shared deliberation across the clinical, administrative, legal, and ethical aspects of MAiD in pediatric settings (41,42). The development of equivalent structures in pediatric settings, with the systematic inclusion of PPC teams, may strengthen collaboration pathways with adult MAiD programs and enhance professional and organizational preparedness to respond to MAiD-related situations, regardless of whether pediatric teams are directly involved in MAiD provision. Such mechanisms can help ensure that emerging MAiD-related situations are addressed at an institutional level, with appropriate resources and shared responsibility, rather than resting solely on teams (37).

Our analysis proposes an original typology of MAiD-related interactions, enhancing understanding of their nature, complexity and dynamics in pediatric context, adding depth to prior conceptualization(10,15 ,37). From this typology, we developed clinical vignettes as reflective tools to support HPs in navigating ethically and emotionally complex situations where patients or parents initiate a MAiD-related interaction. Such tools are effective in palliative care training, anchoring learning in clinical practice, promoting reflective approaches, and reducing anxiety related to uncertainty (43–46).

These vignettes could be integrated into workshops structured around the six interrelated domains of the MAiD experience: medical, legal, moral, ethical, cultural, and psychosocial (47). In pediatric settings, these workshops could explore PPC-specific elements (e.g., team roles, MAiD alternatives) and foster ethical reflection on key themes (e.g., best interest, consent). A Belgian PPC team offers interdisciplinary training that includes euthanasia-related content (5). Similar programs could integrate our vignettes and additional ones could also be co-created with learners to encourage engagement and contextualization (48), adapted for simulation-based training (49,50) or transformed into video vignette formats (51).

Study limitations

This retrospective case study focused on MAiD-related interactions documented within a PPC team, enabling examination of how they emerge and unfold within clinical practice and along EOL trajectories. Although interactions with other HPs and the perspectives of patients and parents were not captured, this design enabled an initial empirical exploration of a highly sensitive and underexplored topic. As a single-site study conducted within a specific social, legal and clinical context, findings may limit direct transferability. However, in-depth analysis within Quebec, -marked by its own legislation and the highest rate of deaths by MAiD in Canada-, also constitutes a strength by enabling early identification of emerging MAiD-related interactions in pediatric care.

Although the small sample size reflects the rarity of MAiD-related interactions in pediatrics and the need to limit data disclosure to preserve confidentiality, it was sufficient to illustrate their diversity and support typology and vignettes development. Case identification relied on team recall and the presence of specific note in the medical records, which may have introduced recall bias and incomplete documentation, particularly of implicit interactions (18). This risk was mitigated through systematic cross-referencing of team recollections and consultation records.

Despite these limitations, this study provides an initial characterization of MAiD-related interactions in pediatrics and highlights the need for systematic documentation to strengthen both clinical follow-up and research. The proposed framework may help teams characterize such interactions. Further studies should include diverse perspectives and contexts (17,52) by adapting and implementing our typology.

Conclusion

MAiD presents a significant ethical challenge in Canadian PPC. Although still rare and legally restricted for minors, MAiD-related interactions are increasing and may lead to actual procedures for patients up to 18 years old. Given their profound impact, these situations highlight the need for specialized training to equip pediatric teams for navigating such complex conversations. Our typology and vignettes offer practical tools to foster reflective ethical practice and to better prepare for future challenges.

Supplementary data

Supplementary data are available at Paediatrics & Child Health online.

Funding

This research is part of a doctoral thesis funded by the Fonds de Recherche du Québec – Santé, Doctoral Training Scholarship (334412), the Blanchard Family Chair for Research and Education in Palliative Care Graduate Research Scholarship, The Université de Montréal Faculty of Medicine/CHU-Sainte-Justine/CISSS Laval Special Agreement for a Doctoral Scholarship in Clinical-Organizational Ethics. It also receives financial support by the Québec Network for Research in Palliative and End-of-Life Care, the Gouverneurs de l'Espoir Funds and the CHU Sainte-Justine Young Researchers Fund “Cercle des Jeunes Chercheurs”.

Potential conflict of interest

The authors reported no conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest.

Ethics

This study was approved by the Ethics Review Board of SJUHC in June 2023 (Certificate 2022-3894). The Board waived the requirement for informed consent, in accordance with institutional and national standards.