A qualitative study of the barriers to and facilitators of the delivery of medical assistance in dying services in Canada from the perspectives of involved professionals

Abstract

Background

Medical Assistance in Dying (MAiD) and related services are legally available in a number of countries under specific conditions and continue to be the subject of ongoing international debate. In Canada, MAiD has been legally available since 2016, with eligibility expanded in 2021 to include individuals whose natural death is not reasonably foreseeable (Track 2), in addition to those whose death is reasonably foreseeable (Track 1). MAiD is federally regulated, but services are organized and delivered at the provincial and territorial levels, resulting in substantial variation in staffing, funding, oversight, and training. To date, most research has focused on the experiences of individual professional groups, such as physicians, or on single jurisdictions. Less is known about how the service delivery process functions as a whole and how its organizational and operational features shape the experiences of the healthcare professionals (HCPs), administrators, and policymakers involved. This study examines the barriers to and facilitators of MAiD service delivery from the perspectives of professionals across the service delivery process throughout Canada and identifies key system-level and operational factors that may inform MAiD policy and program planning both domestically and internationally.

Methods

Participants were recruited through professional networks, provincial and territorial MAiD working groups, and MAiD-related non-profit organizations. Participants included healthcare professionals (HCPs), program administrators, and policymakers involved in MAiD service delivery. Interviews were held virtually and were recorded and transcribed. Data was analyzed using a qualitative descriptive design with a structured, five-phase inductive thematic analysis approach and constant comparison to identify barriers to and facilitators of MAiD service delivery.

Results

A total of 46 semi-structured interviews were conducted between July 2024 and January 2025 with participants from seven provinces and one territory. Ten themes and 25 sub-themes were identified. Barriers included high workloads, limited collaboration with other health services, limited coordination, and inadequate training and financial support. Emerging issues included misinformation about MAiD eligibility criteria, limited bereavement support services for patients’ families, and acquiring and transporting MAiD-related medications. Facilitators included centralized coordination systems, standardized documentation and reporting, interprofessional collaboration, and supportive leadership.

Conclusions

These findings offer a process-level view of how MAiD services have been operationalized in Canada a decade after its legalization. They highlight persistent and emerging challenges in MAiD service delivery as well as promising innovations used to address them. As Canada prepares for the March 2027 expansion of MAiD to persons whose sole underlying medical condition is a mental illness, and as other jurisdictions continue to develop assisted dying legislation, these findings map the system-, operational-, and support-level factors needed to sustain and strengthen MAiD service delivery.

Supplementary Information

The online version contains supplementary material available at https://doi.org/10.1186/s12913-026-14896-2.

Background

Legislative context

Assisted dying services have gained international attention over the past decade as more jurisdictions introduce or consider related legislation. These services include euthanasia, wherein a medical professional administers lethal medication, and assisted suicide, wherein lethal medication is prescribed for patient self-administration [1]. Canada, Belgium, the Netherlands, Switzerland, Australia, Luxembourg, and New Zealand, among others, have regulated one or both forms [1]. Other countries, including France, Germany, Ireland, Italy, and the United Kingdom, continue to debate related legislation [1].

In Canada, both patient/self-administered and clinician-administered assisted dying fall under the term Medical Assistance in Dying (MAiD) [2]. In 2015, the Supreme Court of Canada ruled in Carter v. Canada that the prohibition of MAiD was inconsistent with the Canadian Charter of Rights and Freedoms [3]. This led to amendments to the Criminal Code via Bill C-14, permitting MAiD for individuals whose natural death is reasonably foreseeable [3, 4]. In 2021, Bill C-7 expanded eligibility and introduced additional safeguards for individuals whose natural death is not reasonably foreseeable [3]. These two eligibility pathways are classified as “Track 1” and “Track 2” cases, respectively [3, 5]. Since legalization, annual MAiD provisions in Canada have increased steadily, growing from approximately 5,500 in 2019 to over 16,000 in 2024 [6].

Organizational context

While MAiD is federally regulated through the Criminal Code, the organization and delivery of services are managed at the provincial and territorial levels [4, 5]. A pan-Canadian comparison of MAiD programs found that jurisdictions have adopted centralized, decentralized, or hybrid models of service delivery, with variation in staffing, funding, oversight, and training [5]. Some jurisdictions have established dedicated programs with designated public funding, while others integrate MAiD into existing healthcare structures and departmental budgets [5]. The extent to which MAiD programs integrate with broader healthcare services also varies; some programs actively connect patients and families to additional supports, such as counselling and palliative care throughout the process, while others rely on referrals to existing community or institutional services [5]. Practitioners report provisions to Health Canada either directly or through a coordination service, with oversight committees reviewing documentation in most jurisdictions [5]. Training is typically conducted through mentorship, shadowing, and online modules, and while requirements differ across provinces and territories, resources developed by the Canadian Association of MAiD Assessors and Providers (CAMAP) are widely used [5]. This context is further complicated by ongoing ethical debates on the compatibility of MAiD with longstanding medical principles [7, 8], such as those articulated in the Hippocratic Oath, and the duty to preserve life and alleviate suffering [9]. As a result, some institutions and individuals conscientiously object to involvement in MAiD [4, 5, 10]. Policies in some jurisdictions require that objecting providers nonetheless ensure patients are informed of and able to access MAiD services [4, 5].

Operationally, MAiD service delivery involves multiple steps, including the initiation of a request, intake and preliminary assessment, formal eligibility assessments, provision, and post-provision bereavement support for family members [5]. Coordinators, a role typically held by nurses, receive and screen requests, gather patient information, and facilitate access to assessors [5]. In some jurisdictions, coordinators also connect patients and families to additional support services [5]. Under the Criminal Code, both physicians and nurse practitioners are eligible to conduct MAiD assessments and provisions, provided they meet jurisdictional credentialing requirements [2, 3]. Two independent assessments are required to determine eligibility, and in some cases, specialists are consulted to provide additional expertise on the patient’s condition, eligibility, and capacity to consent [3, 5]. Following completed assessments, MAiD is provided through either clinician-administered or self-administered medication [5].

Empirical context

Since legalization, a growing body of Canadian research has examined professional experiences with MAiD, including the perspectives of physicians [10–14], nurses and nurse practitioners [15], care coordinators [16], health leaders [17, 18], and mixed provider groups [19–22], as well as regulatory practice standards [5] and educational developments in MAiD training [23]. Scoping and systematic reviews have further synthesized provider experiences, barriers to access, and health-system implications across Canada [7, 8, 24, 25]. Studies on assisted dying services have also been published internationally [26, 27]. These studies have addressed important questions about what it is like to work within MAiD as a particular professional or in a specific jurisdiction, but the question of how the service delivery process functions as a whole, and how its organizational and operational features shape professional experiences, has been less explored. Answering these questions can inform the adaptation of existing programs as Canada prepares for the expansion of MAiD eligibility to persons whose sole underlying medical condition is mental illness [3], and the design of new ones as jurisdictions such as France, Germany, and the United Kingdom continue to develop assisted dying legislation. The objective of this study is to examine the barriers to and facilitators of MAiD service delivery in Canada from the perspectives of professionals across multiple roles and jurisdictions, and to identify key system-level and operational factors that may inform MAiD policy and program planning both domestically and internationally.

Methods

This study draws on data collected within a larger Health Canada-funded project examining the implementation of MAiD services in Canada. Phase 1.1 of the project focused on structures and organization of MAiD services in jurisdictions across Canada [5]. The present paper reports findings of phase 1.2 of this project, focused on the barriers to and facilitators of MAiD service delivery from the perspective of the professionals involved in the MAiD process. Phase 2 focused on family experiences with MAiD services [28].

Recruitment: (a) Healthcare professionals (HCPs), including physicians, nurse practitioners, nurses, and social workers; program administrators; and policymakers across Canada were initially recruited for the larger project. They had been identified through existing professional contacts within the health system, requests to provincial and territorial MAiD government working groups to share contact information, and searches for contact information on the websites of provincial and territorial MAiD programs. At the end of each interview for phase 1.1 of the project, interviewees were invited to participate in a separate interview for phase 1.2. They were also asked to refer colleagues (snowball sampling).

(b) In addition, MAiD-related non-profit organizations (e.g., CAMAP, Dying with Dignity Canada) were contacted and were asked to share information about the study with their members. The number of participants recruited was based on efforts to ensure equitable representation from Canadian jurisdictions and saturation of themes.

Data collection: A semi-structured interview guide focusing on perceptions relating to the implementation of MAiD services was created and is available in the supplementary materials. This interview guide has not been published elsewhere and was structured around aspects of MAiD service delivery that were identified in phase 1.1. The interview questions were pilot tested with one senior health executive involved in MAiD. All interviews were conducted virtually using Zoom software (Zoom Video Communications, Inc., San Jose, California, USA) in real time, with one participant, a member of the research team, and one of the authors (TS and DM), each of whom had over 20 years of experience engaging with diverse stakeholder communities across qualitative health systems research. Each interview had one author lead questioning while a member of the research team took notes and managed the recording. Interviews were recorded and transcribed using the built-in features of the Zoom software with participant consent. Transcripts were manually reviewed by AQ and the research team to ensure accuracy and consistency with the recordings. Participants were made aware of the objectives of the research and the general background and goals of the interviewers. Interviews were not repeated. All participants had received a summary of their transcripts and a copy of the findings and were asked to provide feedback on their accuracy and to contribute any additional information they considered missing.

Transcripts were analyzed manually without the use of qualitative data analysis software by AQ and members of the research team. The analysis followed a qualitative descriptive design using an inductive thematic approach drawn from a structured five-phase qualitative data analysis framework adapted from Bingham [29]. First, transcripts were organized using attribute codes for participant roles and region. Second, quotes from transcripts were categorized according to the steps in the MAiD process, with each step subdivided into perceived facilitators and barriers. Third, open coding with constant comparison was conducted to identify barriers and facilitators of service delivery across participants’ perspectives. A codebook was then developed and iteratively updated throughout the process to reflect evolving interpretations, with memos used to document coding decisions and reflections from team members. Fourth, patterns and codes were grouped into themes through discussion among the research team, and representative quotes were selected to support each theme. Fifth, findings were discussed and contextualized within existing literature. The research team included individuals with training in health systems research. The analysis was conducted with attention to reflexivity, including ongoing discussions within the research team to consider how perspectives and assumptions may have influenced data interpretation. Reporting of this study was informed by the COREQ checklist.

Results

A total of 46 participants were interviewed between July 2024 and January 2025. Interviews took 40 to 90 minutes each. Participants were from seven provinces and one territory in Canada. Participants were situated within individual or private practice (n = 9), institutional or hospital networks (n = 5), regional health authorities (n = 17), and provincial or territorial health authorities (n = 15). HCP roles included MAiD assessors and providers (physicians and nurse practitioners), program coordinators (physicians, nurse practitioners, registered nurses, and social workers), psychosocial support providers (social workers and psychosocial specialists), and specialists (physicians). Program administrator roles included medical directors (physicians) and program managers (nurse practitioners and registered nurses). Policymakers included health executives and ministerial staff. Eight participants had multiple roles; therefore, the total number of role-instances was 57. A detailed breakdown of participant characteristics is provided in Table 1. A summary of the themes and sub-themes is provided in Table 2. Representative quotes, along with additional illustrative quotes, are provided in Table 3. A theme map is provided in Fig. 1. To maintain participant anonymity, specific jurisdiction and role-by-jurisdiction breakdowns are not reported, given the small size of some programs.

Table 1.

Participant characteristics by role, profession, and experience

Category	Role	Na	Profession	Experienceb
Healthcare professionals
	MAiD assessors and providers	28	MD = 19 NP = 9	<2016 = 4 2016–2020 = 20 >2021 = 4
	Coordinators	6	RN = 3 NP = 1 Other = 2	2016–2020 = 3 >2021 = 3
	Psychosocial support	2	SW = 2	2016–2020 = 1 >2021 = 1
	Specialists	2	MD = 2	<2016 = 1 2016–2020 = 1
Healthcare professionals subtotal		38
Program administrators
	Medical directors	6	MD = 6	<2016 = 3 2016–2020 = 3
	Program managers	8	RN = 5 SW = 1 Other = 2	2016–2020 = 4 >2021 = 4
Program administrators subtotal		14
Policymakers
	Policymakers	5	MD = 3 Other = 2	<2016 = 3 2016–2020 = 2
Policymakers subtotal		5
Total role-instancesa		57	46 participants · 8 held combined roles

Abbreviations: MD = physician; NP = nurse practitioner; RN = registered nurse; SW = social worker; Other = advanced practice nurse, clinical nurse specialist, or ministerial staff

a Role counts exceed the number of participants [46] as 8 participants held more than one role and are counted once per role held. Roles are not mutually exclusive. Role combinations are not reported to protect participant anonymity

b Experience reflects the legislative period during which participants first became involved in MAiD: <2016 reflects involvement in planning and organizing services before Bill C-14 was passed. 2016–2020 reflects involvement between the passing of Bill C-14 until the passing of Bill C-7. >2021 reflects involvement after Bill C-7 was passed, removing the requirement that natural death be reasonably foreseeable. Specific start years are not reported to protect participant anonymity

Table 2.

Summary of themes and sub-themes identified in the analysis of the barriers to and facilitators of MAiD service delivery

Theme	Sub-theme	Description	Contribution by roles
			C	MA	MD	P	PM	PS	S
System-level factors: structural and contextual factors that shape the broader conditions within which MAiD services operate
T1: MAiD service delivery support systems	Workforce capacity	Refers to the availability and sustainability of personnel, infrastructure, and organizational resources required to deliver MAiD services.	✓	✓	✓	✓	✓	✓	✓
	Financial resources	Refers to the funding models, dedicated budgets, and financial sustainability of MAiD programs.	✓	✓	✓	✓	✓
T2: Program coordination and oversight mechanisms	Centralized coordination of processes	Refers to the system-level organization of referrals, assessments, and provisions through a centralized system or coordinated role.	✓	✓	✓	✓	✓		✓
	Service improvement initiatives	Refers to the formal and informal efforts to evaluate and adapt service delivery over time.	✓	✓	✓	✓	✓	✓
	Collaborative and stakeholder engagement practices	Refers to how MAiD teams interact with other service areas or stakeholders.	✓	✓	✓	✓	✓
	Operational and regulatory oversight mechanisms	Refers to the systems used to review MAiD documentation, processes, and compliance.		✓	✓	✓
T3: Documentation, reporting and information management systems	Documentation and reporting	Refers to the completion of required forms and records throughout the assessment and provision process, including compliance with federal reporting requirements.	✓	✓	✓	✓	✓	✓
	Electronic medical records	Refers to the digital platforms used to manage patient information and track MAiD-related activities.	✓	✓	✓	✓	✓	✓
T4: Public awareness and education	Cultural acceptance and public education efforts	Refers to the sociocultural context that shapes how MAiD is perceived and the efforts by programs to engage communities, address stigma, and provide culturally sensitive information about MAiD services.	✓	✓	✓	✓	✓	✓
	Access to MAiD information for patients	Refers to the availability, clarity, and consistency of patient-facing information and referral pathways for MAiD services.	✓	✓	✓	✓	✓
T5: Professional training and development procedures	Availability of MAiD education and training	Refers to the structured learning opportunities related to MAiD, including provincial training modules, MAiD curriculum modules by CAMAP, and formal training content.	✓	✓	✓	✓	✓	✓
	Mentorship and shadowing processes	Refers to the practical training through guided observation, peer support, and supervised clinical experience offered to prospective HCPs in preparation for MAiD.		✓	✓	✓	✓	✓
Operational processes: sequential clinical and administrative steps of MAiD service delivery
T6: Referral, coordination and screening processes	Referral and screening practices	Refers to the processes by which patients are identified, triaged, and introduced to MAiD services.	✓	✓	✓	✓	✓	✓
	Coordination and case management processes	Refers to the management of individual MAiD cases, including assigning providers, monitoring progress, and connecting patients to support services.	✓	✓	✓	✓	✓	✓
T7: Eligibility assessments	Logistics of eligibility assessments	Refers to the organization of clinical time, personnel, and travel required to conduct MAiD assessments.	✓	✓	✓	✓	✓	✓
	Virtual assessment methods	Refers to the remote assessment processes conducted using online platforms or virtual meeting software.	✓	✓	✓	✓	✓	✓	✓
	Complex case assessments	Refers to the evaluation of patients designated under Track 2.	✓	✓	✓	✓	✓	✓
	Conscientiously objecting facilities	Refers to institutions that restrict or prohibit the provision or assessment of MAiD on-site due to policy or values.	✓	✓	✓	✓	✓	✓
T8: MAiD provision	Medication accessibility	Refers to the processes by which MAiD medications are obtained, prepared, and delivered to providers.	✓	✓	✓	✓	✓	✓
	Medication administration	Refers to the clinical procedures involved in initiating and managing the delivery of MAiD medication.	✓	✓	✓	✓	✓
	Assessor and provider safety	Refers to the measures taken to reduce risk during MAiD assessments and provisions, especially in home settings.		✓				✓
Support processes: programmatic supports available to patients, families, and MAiD assessors and providers
T9: Patient and family support processes	Family engagement	Refers to the practices used to navigate family dynamics, support decision-making, and uphold patient preferences during MAiD.	✓	✓	✓	✓	✓	✓
	Bereavement and emotional support	Refers to services such as grief counselling, spiritual care, and psychosocial support provided to patients and families during the MAiD process, as well as bereavement support for families and relatives following provision.	✓	✓				✓
T10: Support for MAiD assessors and providers	Operational supports	Refers to the financial, administrative, and logistical supports that enable individual assessors and providers to participate in MAiD alongside other clinical duties.	✓	✓	✓	✓	✓
	Mental health supports	Refers to the formal and informal resources available to MAiD assessors and providers to manage the emotional demands of MAiD work.	✓	✓	✓	✓	✓	✓

Note. Checkmarks indicate that at least one participant from the corresponding professional role contributed to the sub-theme. C = coordinators; MA = MAiD assessors and providers; MD = medical directors; P = policymakers; PM = program managers; PS = psychosocial support providers; S = specialists. Themes are organized across three analytical tiers (see Fig. 1)

Table 3.

Representative and supportive quotes from participants

Theme	Sub-theme	Barrier Quotes	Facilitator Quotes
System-level factors: structural and contextual factors that shape the broader conditions within which MAiD services operate
T1: MAiD service delivery support systems	Workforce capacity	“We feel so burdened by the case management. And dealing with an incredible volume of MAiD patients, recruiting and training new providers is always out of reach. There’s just no time.”– Program manager/coordinator “We don’t have any dedicated space for MAiD, so from an operations and flow perspective that can be challenging, especially when trying to navigate our large system in terms of patients coming in and out of the hospital”– Program manager/coordinator “Our biggest barrier is that we just don’t have enough providers.”– Program manager “Our issue is not funding; it’s finding the right [experienced] people.”– Medical director “We have one administrative support person, but there’s a lot of paperwork related to MAiD—so many steps and so much data.”– Program manager	“We have a strong cohort of clinicians who were engaged from the moment MAiD became legal.”– MAiD assessor and provider “Part of our success was organizational preparation. Our health authority didn’t wait for the law to pass before planning for implementation”– MAiD assessor and provider “The other thing that happened here in this region which I think is fairly unique is that they developed, piloted and funded a hospital-based program.”– MAiD assessor and provider
	Financial resources	“The MAiD program has experienced significant growth in requests, yet financial support for its delivery and administration has remained largely unchanged since its inception.”– Program manager	“One key success was securing dedicated funding to establish a permanent full-time role to support coordination.”– Program manager “Our VP has been very supportive, providing funding to sustain our efforts.”– Program manager
T2: Program coordination and oversight mechanisms	Centralized coordination of processes	“Person A says, “Okay, we’ve sent this to Person B.” Person B calls them back and says, “We’ll be in touch when someone contacts us about picking up your file,” and then the patient hears nothing because Person A has closed the file after sending it to Person B, but Person B doesn’t have time to follow up.”– MAiD assessor and provider “There are no standardized competencies for what coordinators need to be able to do … You have nurses, social workers, spiritual care practitioners, non-clinical people doing this role. So the national coordinators have been discussing what standardized competencies are.”– Program manager/coordinator “Lets say a person has never explored MAiD but they’re admitted in for something acute. The start talking about it and a request is made, its part of the hospital record but its not communicated back to primary care … So who owns the information? Whos responsible for it?”– MAiD assessor and provider	“We have a centralized navigation system that essentially all cases go through. It’s how we find first and second assessors, as well as consultants. It works very well.”– Specialist “I think our hub-and-spoke model, with affiliated providers distributed across the province and a core team supporting them, has been pivotal in improving our turnaround time for MAiD.”– Program manager “We call the clinical coordinator for MAiD, and that’s been unbelievably helpful—a complete game changer in terms of supporting providers and patients.”– MAiD assessor and provider
	Service improvement initiatives	“What’s notable to me about the field of MAiD is the lack of feedback as an assessor and provider. Well, as an assessor, I have just virtually no feedback.”– MAiD assessor and provider “I do think there needs to be more support for navigating challenging cases at the time when they’re happening …. I think that there needs to be funding for that and support in order for that to be to provide the best patient care. And also to provide adequate support for providers when there’s the field of MAiD is getting increasingly complex with increased.”– MAiD assessor and provider	“The approach we’ve taken at the [oversight committee] is that we investigate cases and provide recommendations, but it’s all done in the spirit of being a learning experience. This is about people learning to do the right thing. That’s really been helpful for us.”– Medical director “We are inviting patients and families to let us know how we can do better.”– Program manager “I’ve taken that kind of approach to breaking down our process into what are the problems, what’s working well, and rebuilding”– Program manager
	Collaborative and stakeholder engagement practices	“What you really need is a team of interdisciplinary [professionals who] report to the group and work together to make service work. But that’s not how it works … [coordinator] reports to some kind of nursing VP, I report to a different VP, and my secretary, what [they do] is not controlled by me … We can say we need social work, but social work, they have their own timelines, requirements and things that they have to do. It may have nothing to do with what we think we need done.”– Medical director “She reports to some kind of lead, I report to a different lead, and my secretary does not report to me. She reports to a director. I don’t get to have that much say, even in how my office works.”– Medical director	“We were able to at the beginning, bring together all the stakeholders in order to have a common understanding of the procedures and guidelines.”– Medical director “From the beginning, the MAiD site offered palliative care as well, and it took a while longer for the palliative care folks to acknowledge it. But in the end that was a success.”– Medical director “I do feel that we have a really close connection to palliative care within our region. And that’s something that’s really important.”– MAiD assessor and provider
	Operational and regulatory oversight mechanisms	“What we really need is a team of interdisciplinary professionals who work together to review everything that goes in and goes out and reports on that to make services work. That’s not what we have now.”– Medical director “[on Health Canada’s requirement to report ineligible cases] We honestly have very little idea of that [ineligible cases] because I suspect most of them never come to the coordination center at all. Because we don’t do central coordination because we’re not involved in every case, right from the outset … It happens absolutely, it happens, but we don’t hear about it. And I think the data that we gathered off that is very unreliable.”– Medical director	“So we [the review committee] have a really good working relationship with the health authorities. We have regular monthly meetings with the operational sides of the MAiD and we regularly are in contact, ensuring that we are in compliance with our guidelines, which of course, are derived from the criminal code and all the other legislation.”– Policymaker “[on difficulties in post provision reporting] No, I would say no, there, sometimes we all make little mistakes on it, but I’m really glad to have people vetting it before it goes to the Federal government. So the [ministry] will call me up and say, did you really mean to do that? And whatever? So? Yeah. So it’s not onerous once you get used it”– MAiD assessor and provider
T3: Documentation, reporting and information management systems	Documentation and reporting	“[referring to the federal and provincial sections of reporting] So there was a bit of laziness when creating the forms which kept the questions separate, so we have to answer them 3 times.”– MAiD assessor and provider “The other question that they ask … ‘Does the person consider themselves disabled?’ And you know, any person who has metastatic cancer and is lying in bed, needs help turning, is disabled. But do they consider themselves disabled? Surprisingly, many people say no … And so I just don’t think they’re getting the information that, I think, they want.”– MAiD assessor and provider “There is a lot of fragmentation in documentation, which is not ideal … it’s probably our biggest challenge.”– MAiD assessor and provider	“We [coordination team] have made it very easy in terms of the reporting, so if you fill out the form that we have, then we will transcribe that into the reporting system for you. People do not have to do that themselves.”– Medical director “So anytime we do one of these forms, we are required within [a timeframe] to secure file transfer or fax the forms to the oversight team. They check to make sure that all of the t’s are crossed and the i’s are dotted, and they do an amazing job of making sure everything is filled out perfectly … so that’s another nice thing. As a physician, I do not have to do it myself, that works really well here.”– MAiD assessor and provider
	Electronic medical records	“We do need a better EMR. We’re working across three different EMR platforms and, of course, none of the EMRs speak to each other.”– Program manager “Records often do not come in a timely fashion.”– Program coordinator “We’ve talked about how we can have better information flows, but at this point, we haven’t figured that out, so that’s going to continue to be a challenge.”– Medical director	“There’s EMRs [that] don’t connect with each other at all … In working with IT and Telehealth, there’s a platform that was already available. So they have allowed us, and built us up on this platform … All of our documents are scanned in, the people who have access, I control who has access … It also doubles up as a tool for us to gather the data. It’s streamlined a lot of our process.”– Program manager “With our health information system that got updated a couple of years ago, it absolutely streamlines the process and it’s so much better.”– Program manager
T4: Public awareness and education	Cultural acceptance and public education efforts	“The only other challenge I have is the talking about MAiD piece, the restrictions on educating communities and folks about it. And of course, we’re over 50% indigenous. Therefore, there are nuances with our indigenous population … So not everybody is having the same cultural context for our services.”– Policymaker “There are religious reasons why people are against MAiD.”– MAiD assessor and provider	“I think that community education has been really helpful … the health authority has also offered to do [community education sessions] and the advocacy groups held many sessions … that has led to a very educated population.”– MAiD assessor and provider
	Access to MAiD information for patients	“Still, a lot of clinicians who do not know how they feel about it or who are uncomfortable with it provide incorrect information. In some instances, it may not be intentional, but in others, it’s very intentional, blocking referral.”– MAiD assessor and provider “Information on the website, which is not kept up very well, that could be improved.”– Psychosocial support provider “There’s lack of education in the healthcare world around MAiD and misinformation. So they’re telling patients one thing, and we’re like, ‘No, not at all. That’s not even close to the truth.”– Program manager “People don’t know that it’s even legal. And there are, you know, medical people who think that it’s not necessary.”– MAiD assessor and provider “The main challenge with access is that people either don’t know that MAiD is available or don’t know how to access it.”– MAiD assessor and provider	“The [health authority] websites work really well because they’re kept up to date … The information there is very good … And even if they’re not computer literate they can phone the MAiD offices in each health authority are really very available. So I’d say that works well.”– Medical director “I really encourage our coordinators to go out to each community, whether that’s within a hospice or a home health, or to a palliative care unit in the hospital to get to know the people that are providing the bedside care … I do feel that we have a really close connection to palliative within our Health Authority.”– Program manager “Every healthcare provider in the province kind of knows that if they have a patient requesting MAiD, they know to send it to us. So I think that’s a success.”– Medical director “I think they do a pretty good job of having it published on the website, and they do have the ways to access the program available.”– MAiD assessor and provider
T5: Professional training and development procedures	Availability of MAiD education and training	“CAMAP modules take quite a long time to do and once CAMAP starts charging for them, that’s going to be a significant disincentive.”– MAiD assessor and provider “Well, our educational curriculum is not up to date, that’s probably the biggest issue.”– MAiD assessor and provider	“CAMAP has been an invaluable, priceless, invaluable resource, not just for education, not just for training, not just for guidance and guidelines, but for connection, interconnection with the colleagues that do this work, and just being able to know our community of practice online.”– MAiD assessor and provider “They [the MAiD program] take residents from the family medicine training program that rotates through those hospitals and offer them a MAiD rotation, which has been very effective in terms of education.”– MAiD assessor and provider “With the MAiD curriculum, I think that gives a really good overview and basis for MAiD that has made a big difference.”– MAiD assessor and provider
	Mentorship and shadowing processes	“Unfortunately, mentorship is not always possible, especially in rural, remote locations. Sometimes there’s just nobody there physically to mentor you.”– MAiD assessor and provider	“It’s a good program for people to start out with, the manager and of the [nurse practitioners] will have an hour-long conference and there’s a shadowing process … I think it’s a very solid orientation.”– MAiD assessor and provider “Mentorship is definitely there, we have a good climate for new assessors and providers like, ‘come, follow me,’ or ‘I’ll come, sit in with you,’ sort of thing. So I think climate and creating a supportive network is really important.”– MAiD assessor and provider
Operational processes: sequential clinical and administrative steps of MAiD service delivery
T6: Referral, coordination and screening processes	Referral and screening practices	“It literally is a bit of a lottery. So, if somebody happens to have a family doctor or has one of the nurse practitioners who works for Home Care, they’ve hit the jackpot.”– MAiD assessor and provider “That’s been a bit of a challenge – to come up with something [a screening tool] that achieves the objective, but doesn’t run us afoul of either the legislation or the scope of practice.”– Medical director	“Well, we have multiple routes in, so you can mail it in, and we get about 6 to 10 a week that way. It’s not a small number. You can call. You can talk to your primary care provider, or you can email us directly, because it’s on the website. So, there’s lots of different mechanisms to get into the system. And I think that works.”– Medical director “There were some judgments passed by the Admins, and the Admins never sent me the referral because they felt that the patient didn’t qualify for MAiD, which led to the creation of the centralized referral system.”– Program manager “We’ve developed a screening form because we’re trying to find ways to gain as much information on the clinical situation as possible in order to give our assessors as clear a picture as possible so that they make an informed decision as to whether or not this is something that they would be comfortable taking on.”– Program manager
	Coordination and case management processes	“So, the care coordinator who’s managing and coordinating the patient’s referral at home has no ability to find out or even know whether that patient has requested MAiD previously, unless the patient discloses that to them. They also have no way of following up to see where they are on the list or what’s happened or give any updates to the patient.”– MAiD assessor and provider “Each coordinator has an average of 90 caseloads … it is quite a high caseload for each one of them.”– Program manager	“We have been able to set up a system with the provincial coordination service that does the referral. So, all referrals come directly to all of us on the team, and then whoever’s available accepts the referral, and I think that has streamlined it.”– MAiD assessor and provider “Somebody else who’s covering another area will pick up the request … the coordinators understand their workload, and what’s going on. And so they’re able to spread the requests around. And so that has been really beneficial.”– Program manager
T7: Eligibility assessments	Logistics of eligibility assessments	“Finding time to carry out those assessments around our busy schedules is cumbersome … and that is a challenge.”– MAiD assessor and provider “Of our communities, 10 of them have less than 200 residents, so ensuring equity of services for folks who want to receive MAiD in their community can be a challenge.”– Policymaker “I think that some of the big challenges are still finding assessors and providers.”– MAiD assessor and provider “so one thing that’s happened in the catchments of health authorities with large numbers of patients living in remote communities. Is travel time. And being compensated for travel time. So sometimes like in the interior for example, the provider will have to drive hours to get to the patient.”– Medical director	“We hired a nurse practitioner up north who’s kind of like a resident MAiD provider in there, which is something we didn’t have before. So, that’s something we really needed because we were adding weeks on to those patients’ wait times just to be able to arrange travel to see them.”– Program coordinator “Most of our providers have dedicated time to do MAiD work, so they either have a half day a week or a full day a week of dedicated time that we know about ahead of time so we can book them to see patients.”– Medical director
	Virtual assessment methods	“[on virtual assessments] but you miss out on a lot of body language, you miss out a lot of their environmental context and so it makes it a bit harder to determine eligibility.”– MAiD assessor and provider “It works most of the time but there’s certainly a lot of challenges with technology. A lot of patients are not familiar enough with technology to actually be able to navigate a Zoom meeting or a Teams meeting.”– MAiD assessor and provider “You can’t be reimbursed for it [virtual assessment].”– MAiD assessor and provider “There are some clinicians that won’t do [virtual assessments] because they feel that they’re breaking the rules. And yet we can’t meet the isolated geographic areas because there’s no virtual [billing] codes in place. So I think that would be one logistical operational thing that would help solve some of our northern clienteles access.”– MAiD assessor and provider	“We tend to pair up assessments a lot, and we always try to do both virtual and in-person assessments at the same time. It helps the patients, not having to go through the entire interview twice.”– MAiD assessor and provider “We’ve been trying to do more dual assessments, so having one assessor and a nurse and social worker go to the patient, while also having another assessor virtually attend as well. That way, we can get both assessments done by the independent assessors without having to kind of try and deal with delays because of the scheduling piece.”– Program coordinator “The fact that some of our bylaws have changed to enable virtual care to be used for assessments has enabled patients to basically access MAiD as soon as possible.”– MAiD assessor and provider
	Complex case assessments	“The problem we have had is that it takes a long time to complete all the assessments, particularly for Track 2, and to make sure the different specialties have seen the patients. Getting appointments with a specialist is always tricky.”– MAiD assessor and provider “We have a very small handful of people who are willing to do Track 2 assessments because they tend to be very time consuming, very complicated, and go way beyond medicine into all of the social determinants of health.”– MAiD assessor and provider “Track 2 is a very heterogeneous population, certainly there are people with Alzheimer’s, chronic diseases, COPD, heart failure … That has been very challenging.”– Medical director “[Track 2 cases] are also very litigious … so that has some of our team very fearful, right? So they don’t want to do Track 2, because of the fear of complaints and litigiousness. And so that’s been a barrier.”– Medical director	“We have a complex case review where we will take our team and the medical director and do a presentation about what it is about this person’s care that makes them complex. Then, with the medical director’s advice or support, we will assemble a plan to do an assessment.”– Program manager “We have nurse coordinators who do a very in-depth triage. And then any kind of questionable patients come to me as [Medical director] for review. So patients that get through to be assessed are usually by that point, fairly certain that they’re eligible. So we kind of protect our group of assessors and providers. And so they are willing to see Track 2 because they know when they’re actually asked to see a Track 2, most of the hard work is kind of already done.”– Medical director
	Conscientiously objecting facilities	“And we have to decline people because they’re not safe to transfer. And that’s really hard to tell people that you can’t have MAiD because of where you are, and we can’t move you without it because you don’t want to die in a van. So, we do decline people we don’t think are safe to transfer.”– Program manager “I think it’s quite a logistical challenge to move someone to another space, to find the day that works, and then accommodate when they can get there. It’s essentially like admitting them into another place. There’s all this paperwork that goes along with it and it’s a huge nightmare.”– Program manager “We’ve had an example in one nursing home … did not let the patient access MAiD, or would not assist the patient in accessing any information about MAiD, because they didn’t believe in. And that’s completely unethical.”– Program manager	“One of our successes was getting those objecting sites to agree that everything other than the provision could occur there, because for many years, that was not possible.”– Medical director “One of the things that I’m most proud of … is the ability to address conscientious objection in a way that met the needs of everybody … We [regulators, colleges, other stakeholders] have a common table that we attend, and they’ve all participated, and they continue to participate”– Medical director
T8: MAiD provision	Medication accessibility	“One challenge that I’m dealing with a lot is that we are struggling with having willing pharmacies to dispense medication kits within communities.”– MAiD assessor and provider “One of the challenges would be the organization that we go through to get our MAiD medications requires 72 h notice.”– MAiD assessor and provider “For the pharmacy to do the medication, the patient has to be admitted, even if they’re going to be at home, because it’s only the hospital pharmacies that prepare the medications. So, they have to be admitted, and they have to be admitted at the right time.”– Medical director	“If you need the medication to be sent to you, they would have a bonded courier take them from a bigger facility to that remote facility. It’s a necessary safeguard.”– MAiD assessor and provider “One of the things that we do as well now is request that the pharmacy supply the medications in pre-filled syringes. Not all of them will, but many of them do now, and we try to encourage that because it has been helpful in terms of expediting the process.”– Medical director
	Medication administration	“The nursing availability for IV starts is often a challenge.”– MAiD assessor and provider “I’ve had a case where we’ve been in the home of a patient with [an] access device, [and] it’s been extremely difficult to do IVs in them. It’s taken multiple attempts and pokes. But if the nurse who’s there is not allowed to access that device, because [of] the protocols, then we have to use IVs or we have to try to drive someone from the hospital who’s competent and interrupt their day to come.”– MAiD assessor and provider	“They have nurses who do IVs. And I just send them an order, and they usually do it either the afternoon before or the same morning, which works well.”– MAiD assessor and provider “A nurse always tries to go assess IV access beforehand and if there are concerns, we try to make arrangements for an alternate IV before we arrive.”– Medical director
	Assessor and provider safety	“I once had to call the police and say, ‘Can you escort me? I’m very worried.’ This woman was threatening to shoot me and what do I do?”– MAiD assessor and provider “Some homes aren’t particularly comfortable to be in, you know, there can be safety issues.”– MAiD assessor and provider “Ideally, you’d prefer if you’re going to someone’s home, you don’t want to be doing it by yourself. But that tends to be what the scenario is … I think safety is probably the main concern when going into someone’s home.”– MAiD assessor and provider	“We also look at the safety of those assessors, and we would never send one person alone to see somebody.”– Program manager “It’s also very good to know that our first medical director, and then the medical director we have now, all talk about our personal safety. If we don’t feel personally safe … we’re supported in adjusting the times, and I believe I would be supported in not being involved in that case, so I feel that for myself, I feel supported in this.”– MAiD assessor and provider
Support processes: programmatic supports available to patients, families, and MAiD assessors and providers
T9: Patient and family support processes	Family engagement	“We’ve had cases where the family member was absolutely refusing that the patient proceeds with MAiD.”– Program manager “We’ve had people from family who have shown up that are in disagreement. That’s always a challenge.”– MAiD assessor and provider	“We have a strong kind of support system through social work for families, patients, and families, but including bereavement, counseling and grief support. So that’s definitely a success.”– Medical director “And so, then we work with the patient to support whatever their wishes are, and sometimes we have patients that say, ‘I don’t want my family knowing that I’m doing this,’ so then we’ll push back to them, and say, ‘well, how do you want your family to find that you’ve died?’ We have those kinds of conversations with them, and that’s what I think is the best part of our social workers, they are very well versed in conversations around end of life, and they say those difficult phrases, and they’re invested in having those conversations with patients. So, we would heavily utilize and try to mediate between the family and the patients and try to mend those relationships.”– Program manager “We offered a family meeting for patients and family members to come, so that family members could ask questions from a reliable source.”– MAiD assessor and provider
	Bereavement and emotional support	“I mean there’s recognition that bereavement is something we need to support. But the resources are very thin.”– Specialist “Some areas of the province have better access to [bereavement] supports than others, some have no access at all. But it really isn’t something that, unless we had the funding for it, we can directly influence.”– Medical director	“I would say a large part of what makes us successful has nothing to do with the medical aspect of things; it has to do with the psychosocial aspect of things.”– MAiD assessor and provider
T10: Support for MAiD assessors and providers	Operational supports	“Compensation at the moment is one of them. That’s a fairly strong challenge. The fee-for-service rate is not competitive with the current pay scale that a family physician can earn if they sit in their office doing office work.”– MAiD assessor and provider “They’re already doing too much for the little amount of pay that they’re getting.”– MAiD assessor and provider “I will get paid as a community MAiD practitioner. If my patient happens to be admitted to hospital, I get paid less to do a MAiD procedure there than I do when the patient’s at home. It makes no sense, because I have to work just as hard. I have to go to the hospital just like I go to the patient’s home … I don’t think it is fairly compensated.”– MAiD assessor and provider “Nurse practitioners are a whole different kettle of fish, because up until recently they’ve not had the ability to bill as independent practitioners. And, in fact, that system is still not yet in place to my knowledge. … have come up with some operational funding to pay them or their home department has been willing to give them certain number of hours a month to contribute to this activity out of what they’re already being paid for by their home department”—Medical director	“We’re compensated for all of the time filling out the forms ahead of time and traveling to the community and everything. That’s all compensated, which I think is important and fair, and what needs to be done for people to do this work.”– MAiD assessor and provider “we negotiated a payment contract, a payment process whereby providers from bigger communities and this is physician, payment. This is not nurse practitioner … And so, as a part of that, we pay people to travel into smaller communities. And we also, as part of that, we pay them to mentor those in smaller communities, and we pay the people being mentored to come and be mentored, and those have both proved useful over time In order to increase the number of providers in smaller communities.”– Medical director
	Mental health supports	“Right now, we do not have any official debriefing process in place. We do not have any sort of process in place following, you know, an especially difficult provision or a time out to sort of collect yourself. We just do not have that built into our process at all, and I find that is really like morally distressing.”– MAiD assessor and provider “I do feel quite on an island out here, I feel pretty isolated, especially when I was starting. I really only knew of one other provider in the area, and if she wasn’t available I did not know who to turn to for help and just even emotional help. It’s a difficult thing to do.”– MAiD assessor and provider	“We have built into our team social workers, and we do a kind of debrief with each other as a team. And we do a reach out to all of the external nurses and social workers and meet monthly with an Employee Assistance Program.”– Medical director “We have sort of the Provider support group. So we have little Whatsapp group for providers within [jurisdiction], and just sort of float cases or questions or things like that. And then the Provider support group is open to anybody in the [region] who does assessments and provisions, Or even people who are just curious about it. And they meet [twice] a month … You can kind of ask the group’s opinion. You can talk about difficult situations you’ve been in to kind of debrief, and the value of it is, you’re talking to other people also involved in this work.”– MAiD assessor and provider “I have lots of colleagues that I chat with, and we share and commiserate. And yeah, CAMAP for sure, like the forums, and the ability to like meet in person at the conferences and case sharing and stuff, and hear from other people who are going through the same things that we are.”– MAiD assessor and provider

Fig. 1.

Thematic map of the barriers to and facilitators of MAiD service delivery. Ten themes (T1–T10) and 25 sub-themes were identified through inductive thematic analysis and are organised across three nested dimensions of service delivery. The outermost tier, system-level factors (T1–T5), describes the structural and contextual conditions within which MAiD services operate. Nested within is operational processes (T6–T8), the sequential clinical and administrative pathway from referral and screening through eligibility assessment to provision. Nested within the operational tier is support processes (T9–T10), the programmatic supports available to patients, families, and MAiD assessors and providers; T9 and T10 are presented as full-width bars within rather than alongside the operational tier because these supports are embedded at each step of service delivery rather than operating separately from it

Following the analysis described above, ten major themes with 25 sub-themes were identified. Themes 1–5 were organized to reflect the structures and systems that support MAiD programs. Themes 6–8 aligned with the typical process of MAiD services, from referral to post-provision supports. Theme 9–10 focus on supports to assessors and providers involved in service delivery and to patients and families throughout the care process.

Theme 1: MAiD service delivery support systems

MAiD service delivery support systems encompass workforce and financial resources that enable the delivery and sustainability of MAiD services.

Sub-theme: Workforce capacity

In several jurisdictions, participants identified limited availability of assessors, providers, and support personnel (e.g., program coordinators, community nurses, administrative assistants, and social workers) as barriers to service delivery. These workforce shortages had been compounded by the increased quantity and complexity of cases, and high administrative burden. In some jurisdictions, MAiD teams had physically lacked dedicated administrative and clinical space, and in settings where patients had not wished to receive MAiD at home, identifying appropriate alternative locations for provision had presented additional challenges.

We feel so burdened by the case management. And dealing with an incredible volume of MAiD patients, recruiting and training new providers is always out of reach. There’s just no time.– Program manager/coordinator

We don’t have any dedicated space for MAiD, so from an operations and flow perspective that can be challenging, especially when trying to navigate our large system in terms of patients coming in and out of the hospital– Program manager/coordinator

In contrast, other jurisdictions had established MAiD programs supported by a strong cohort of assessors, providers, and support personnel with experience in MAiD or end-of-life care. Early planning and proactive engagement by health authorities and program teams had facilitated the development of dedicated MAiD teams, including hospital-based and interdisciplinary team structures. Some jurisdictions had designated spaces for MAiD provision or had agreements with external facilities to serve as alternative provision sites.

We have a strong cohort of clinicians who were engaged from the moment MAiD became legal.– MAiD assessor and provider

Sub-theme: Financial resources

In some jurisdictions, limited financial resources had constrained the ability of MAiD programs to maintain or expand service delivery. While the number of requests had increased, funding allocations had remained largely unchanged, which created challenges in sustaining service delivery and integrating additional supports, such as counselling or bereavement services.

The MAiD program has experienced significant growth in requests, yet financial support for its delivery and administration has remained largely unchanged since its inception.– Program manager

Where dedicated funding had grown alongside increasing demand, programs had been able to expand services, improve implementation, and support recruitment.

One key success was securing dedicated funding to establish a permanent full-time role to support coordination.– Program manager

Theme 2: Program coordination and oversight mechanisms

Program coordination and oversight mechanisms encompass the structures and practices used to organize service delivery, implement quality improvement, engage relevant stakeholders, and provide oversight of MAiD programs.

Sub-theme: Centralized coordination of processes

In jurisdictions without such systems, participants had described challenges in coordinating assessments, arranging support services, and maintaining consistent communication, particularly during transitions between care settings. These challenges had been exacerbated by the lack of standardized protocols, which had contributed to variations in referral procedures and confusion over responsibilities.

Person A says, “Okay, we’ve sent this to Person B.” Person B calls them back and says, “We’ll be in touch when someone contacts us about picking up your file,” and then the patient hears nothing because Person A has closed the file after sending it to Person B, but Person B doesn’t have time to follow up.– MAiD assessor and provider

There are no standardized competencies for what coordinators need to be able to do … You have nurses, social workers, spiritual care practitioners, non-clinical people doing this role. So the national coordinators have been discussing what standardized competencies are.– Program manager/coordinator

In jurisdictions with centralized coordination systems, referrals, assessments, and provision had been coordinated through standardized processes that improved timeliness and continuity of care. These models had decreased the administrative workload on assessors and providers and had enhanced communication across the care team.

We have a centralized navigation system that essentially all cases go through. It’s how we find first and second assessors, as well as consultants. It works very well.– Specialist

Some jurisdictions had adopted hybrid approaches that combined centralized coordination with decentralized service delivery. Such approaches include hub-and-spoke models, wherein referrals had been centrally coordinated and distributed to assessors and providers in the community, which had improved workload distribution and expanded access to patients in rural or remote communities.

I think our hub-and-spoke model, with affiliated providers distributed across the province and a core team supporting them, has been pivotal in improving our turnaround time for MAiD.– Program manager

Sub-theme: Service improvement initiatives

In some jurisdictions, participants had described the lack of formal mechanisms for feedback and review, particularly for assessors and providers, which had limited opportunities to identify and address gaps in practice. Although reporting processes had been established, the extent to which they had contributed to system-wide learning or service improvement remained unclear.

What’s notable to me about the field of MAiD is the lack of feedback as an assessor and provider. Well, as an assessor, I have just virtually no feedback.– MAiD assessor and provider

In contrast, some programs had embedded feedback mechanisms into their standard procedures, and had drawn on input from patients, families, staff, literature, data, and oversight committees. In some cases, this had been supported by a broader culture of continuous quality improvement, in which some programs had adopted a Lean lens approach (i.e., focused on improving efficiency and reducing waste).

The approach we’ve taken at the [oversight committee] is that we investigate cases and provide recommendations, but it’s all done in the spirit of being a learning experience. This is about people learning to do the right thing. That’s really been helpful for us.– Medical director

Sub-theme: Collaborative and stakeholder engagement practices

Some participants had experienced challenges integrating MAiD within the broader healthcare system due to limited collaboration with other departments and service areas. In some settings, MAiD programs had functioned in isolation from related service areas, such as palliative care, resulting in siloed processes and disjointed service delivery. These challenges had been compounded by structural constraints, where team members worked under separate mandates, timelines and belonged to different organizational units. In the absence of integrated infrastructure or shared procedures, team members had limited influence over how services were coordinated or how roles and responsibilities aligned across programs.

What you really need is a team of interdisciplinary [professionals who] report to the group and work together to make service work. But that’s not how it works … [coordinator] reports to some kind of nursing VP [vice-president], I report to a different VP, and my secretary, what [they do] is not controlled by me … We can say we need social work, but social work, they have their own timelines, requirements and things that they have to do. It may have nothing to do with what we think we need[s] done.– Medical director

In some programs, early and sustained engagement with stakeholders across clinical, regulatory, and administrative functions had supported the development of shared procedures and a common understanding of how MAiD would be delivered. This collaborative approach had established strong relationships with related service areas, particularly palliative care, and had laid the groundwork for embedding MAiD more fully within the healthcare system.

We were able to at the beginning, [to]bring together all the stakeholders in order to have a common understanding of the procedures and guidelines.– Medical director

Sub-theme: Operational and regulatory oversight mechanisms

In some programs, participants had described how limited oversight mechanisms for reviewing processes and procedures had hindered efforts to achieve consistency in care delivery. Where oversight mechanisms had existed, their focus was typically confined to post-provision reporting, which had resulted in fewer opportunities to identify and address issues prior to provision. Additionally, a lack of interdisciplinary oversight teams had narrowed the perspectives available to support decision-making. Oversight practices had also varied across jurisdictions, with few standardized frameworks in place to consistently track incomplete or ineligible MAiD cases. These experiences had been further shaped by varying interpretations of legislative criteria across assessors and jurisdictions, with limited mechanisms in place to reconcile differences in clinical judgment.

What we really need is a team of interdisciplinary professionals who work together to review everything that goes in and goes out and reports on that to make services work. That’s not what we have now.– Medical director

In some programs, operational oversight had been supported by dedicated oversight units, administrative staff, and program coordinators who assisted with documentation and reviewed it for legislative compliance. Collaboration between oversight units and program staff had supported consistent documentation and data collection. Some programs had also held routine case reviews and clinical discussions, which had contributed to shared understanding and consistency in clinical decision-making.

So we [the review committee] have a really good working relationship with the health authorities. We have regular monthly meetings with the operational sides of the MAiD and we regularly are in contact, ensuring that we are in compliance with our guidelines, which of course, are derived from the criminal code and all the other legislation.– Policymaker

Theme 3: Documentation, reporting and information management systems

Documentation, reporting and information management systems encompass the processes and systems used to complete required documentation, comply with reporting obligations, and manage patient information through electronic medical records.

Sub-theme: Documentation and reporting

In many programs, participants had described how the volume and complexity of forms and the duplicative reporting to both provincial/territorial and federal authorities had contributed to time-consuming documentation processes. Participants also noted under-reporting of cases where patients were found ineligible or had not yet completed a written request, as well as template questions that did not align with clinical realities or required clinician input for non-clinical content.

[referring to the federal and provincial sections of reporting] So it there was a bit of laziness when creating the forms which kept the questions separate, so we have to answer them three times.– MAiD assessor and provider

The other question that they ask … ‘Does the person consider themselves disabled?’ And you know, any person who has metastatic cancer and is lying in bed, needs help turning is disabled. But do they consider themselves disabled? Surprisingly. Many people say no … And so I just don’t think they’re getting the information that, I think, they want.– MAiD assessor and provider

To address these challenges, some programs had established support mechanisms to streamline documentation and reporting. MAiD program coordinators and administrative staff had played active roles in assisting with the preparation, review, and submission of required forms, while oversight units had provided quality assurance and legal guidance. Some programs had developed simplified reporting templates compliant with legislative requirements.

We [coordination team] have made it very easy in terms of the reporting, so if you fill out the form that we have, then we will transcribe that into the reporting system for you. People do not have to do that themselves.– Medical director

So anytime we do one of these forms, we are required within [a timeframe] to secure file transfer or fax the forms to the oversight team. They check to make sure that all of the t’s are crossed and the i’s are dotted [forms are fully completed with attention to detail], and they do an amazing job of making sure everything is filled out perfectly … so that’s another nice thing. As a physician, I do not have to do it myself, that works really well here.– MAiD assessor and provider

Sub-theme: Electronic medical records (EMR)

In some programs, participants had faced limited or inconsistent access to EMRs. Where paper-based systems were still in use, participants reported delays in retrieving clinical information and challenges in sharing records across teams. Even in settings with EMRs, incompatible platforms between health authorities had reduced access to information and limited the ability to coordinate care.

We do need a better EMR. We’re working across three different EMR platforms and, of course, none of the EMRs speak to each other.– Program manager

In some programs, information systems had been updated to improve access and communication for MAiD teams. These updates had included centralized EMR portals and tracking tools to monitor case progress. In some cases, access to existing systems had been extended through approval processes to include community-based or retired assessors and providers.

There’s EMRs [that] don’t connect with each other at all … In working with IT and Telehealth, there’s a platform that was already available. So they have allowed us, and built us up on this platform … All of our documents are scanned in, the people who have access, I control who has access … It also doubles up as a tool for us to gather the data. It’s streamlined a lot of our process.– Program manager

Theme 4: Public awareness and education

Public awareness and education encompass the sociocultural context in which MAiD is perceived and discussed, public outreach efforts undertaken by programs to aid comprehension of MAiD services, and the accessibility of information for prospective patients.

Sub-theme: Cultural acceptance and public education efforts

In some settings, participants described how persistent stigma, alongside religious and moral opposition, had contributed to limited cultural acceptance of MAiD services. Public education efforts had been constrained by a lack of culturally relevant materials, limited forums for public dialogue, and hesitancy to engage in outreach due to concerns about promoting MAiD.

The only other challenge I have is the talking about MAiD piece, the restrictions on educating communities and folks about it. And of course, we’re over 50% indigenous. Therefore, there are nuances with our indigenous population … So not everybody is having the same cultural context for our services.– Policymaker

Some programs had implemented community-based initiatives to reduce stigma and support cultural acceptance of MAiD. These had included partnerships with cultural and religious leaders, community organizations, and spiritual advisors to facilitate respectful dialogue on end-of-life care. Programs had also promoted discussion within the health sector to address professional resistance and had clarified legislative and procedural aspects of MAiD. Outreach efforts to inform the public had been supported by dedicated staff, community presentations, and educational materials.

I think that community education has been really helpful … the health authority has also offered to do [community education sessions] and the advocacy groups held many sessions … that has led to a very educated population.– MAiD assessor and provider

Sub-theme: Access to MAiD information for patients

In some programs, participants had described how access to MAiD-related information had been limited by inconsistent referral practices, overlapping communication channels, and insufficient funding for disseminating accurate information about MAiD to prospective patients. Targeted outreach to specific populations had often been lacking, and some healthcare professionals had shown limited awareness or active resistance to referring patients for MAiD, which had contributed to confusion among prospective patients about service availability, eligibility, and safeguards.

Still, a lot of clinicians who do not know how they feel about it or who are uncomfortable with it provide incorrect information. In some instances, it may not be intentional, but in others, it’s very intentional, blocking referral.– MAiD assessor and provider

Information on the website, which is not kept up very well, that could be improved.– Psychosocial support provider

In contrast, some programs had used coordinated and centralized approaches to improve access to MAiD-related information for prospective patients. These had included centralized coordination teams, engagement with the broader healthcare community to disseminate consistent information, and referral pathways to connect patients with program or community-based support. Some jurisdictions had implemented policies addressing conscientious objection at the individual provider level, such as requiring providers to disseminate accurate information about MAiD and appropriately refer patients to MAiD programs and resources.

The [health authority] websites work really well because they’re kept up to date … The information there is very good … And even if they’re not computer literate they can phone the MAiD offices in each health authority … So I’d say that works well.– Medical director

Theme 5: Professional training and development procedures

Professional training and development procedures encompass education and practical training that prepare professionals for delivering MAiD services.

Sub-theme: Availability of MAiD education and training

Participants had identified a lack of national standardization and accreditation for MAiD, outdated and inconsistently localized provincial curricula, and a lack of inclusion of MAiD in broader health-professional training curricula as consistent challenges. Furthermore, MAiD-specific curricula for roles other than assessors and providers had been limited or absent. Where MAiD-specific curricula had existed, such as those offered by CAMAP, participants had raised concerns about lengthy time commitments, non-localized content, and potential future fees.

CAMAP modules take quite a long time to do and once CAMAP starts charging for them, that’s going to be a significant disincentive.– MAiD assessor and provider

In some jurisdictions, accreditation standards, educational curricula, or localized CAMAP modules had been developed. In some cases, voluntary clinical MAiD rotations for family medicine residents and practicum placements for nurse practitioners had been launched to increase awareness and build future capacity among healthcare professionals. Despite concerns raised by some jurisdictions about the CAMAP MAiD curriculum, it was still widely recognized as an invaluable resource for MAiD-related education.

CAMAP has been an invaluable, priceless, invaluable resource, not just for education, not just for training, not just for guidance and guidelines, but for connection, interconnection with the colleagues that do this work, and just being able to know our community of practice online– MAiD assessor and provider

They [The MAiD program] take residents from the family medicine training program that rotates through those hospitals and offer them a MAiD rotation, which has been very effective in terms of education.– MAiD assessor and provider

Sub-theme: Mentorship and shadowing processes

Across jurisdictions, mentorship and shadowing opportunities had been recognized as critical to building competency and confidence among new assessors and providers. However, these opportunities had remained limited, particularly in rural and remote areas with fewer resources, where access to experienced mentors had been scarce.

Unfortunately, mentorship is not always possible, especially in rural, remote locations. Sometimes there’s just nobody there physically to mentor you.– MAiD assessor and provider

Some programs had developed structured onboarding procedures that included mentorship and shadowing; these procedures had provided opportunities for consistent exposure to MAiD processes, peer learning, and skills development. In some jurisdictions, mentors were paid to provide MAiD and to mentor prospective assessors and providers in rural communities.

It’s a good program for people to start out with, the manager and the [nurse practitioners] will have an hour-long conference and there’s a shadowing process … I think it’s a very solid orientation.– MAiD assessor and provider

Theme 6: Referral, coordination and screening processes

Referral, coordination, and screening processes encompass the initial stage of the MAiD process, where patients first engage with MAiD services.

Sub-theme: Referral and screening practices

In some jurisdictions, these practices had remained inconsistent, particularly in the absence of unified, mandatory points of entry and standardized screening protocols. Although centralized coordination services had existed in many regions, patients could access MAiD assessors and providers through alternative routes, such as direct referral from another clinician or by identifying a provider on their own without the involvement of the coordination team. This fragmentation had led to variability in referral procedures and inconsistencies in how patients were introduced to MAiD.

It literally is a bit of a lottery. So, if somebody happens to have a family doctor or has one of the nurse practitioners who works for Home Care, they’ve hit the jackpot.– MAiD assessor and provider

Program coordinators had faced additional challenges in data collection when screening patients. Challenges had included a lack of standardized screening tools, instances where patients did not have a primary care provider, and regulatory constraints on coordinators’ scope of practice. These had limited program coordinators’ ability to obtain necessary medical and contextual information during intake or conduct preliminary eligibility assessments.

That’s been a bit of a challenge to come up with something [a screening tool] that achieves the objective, but doesn’t run us afoul of either the legislation or the scope of practice.– Medical director

In other jurisdictions, centralized referral systems with multiple points of access and clearly defined screening and triaging processes had been established. These processes had supported workload distribution and case management, had lowered wait times, and had reduced confusion among healthcare professionals.

Well, we have multiple routes in, so you can mail it in, and we get about 6 to 10 a week that way. It’s not a small number. You can call. You can talk to your primary care provider, or you can email us directly, because it’s on the website. So, there’s lots of different mechanisms to get into the system. And I think that works.– Medical director

Sub-theme: Coordination and case management processes

Participants had described high case volumes and complex patient needs as prominent challenges in the context of continually rising demand. In the absence of dedicated coordination services, additional challenges had emerged, including limited mechanisms for tracking referrals, sharing updates, ensuring continuity across service providers, and connecting to supports that fell outside the MAiD team’s expertise.

So, the care coordinator who’s managing and coordinating the patient’s referral at home has no ability to find out or even know whether that patient has requested MAiD previously, unless the patient discloses that to them. They also have no way of following up to see where they are on the list or what’s happened or give any updates to the patient.– MAiD assessor and provider

In jurisdictions with fully or partially centralized approaches, care coordination teams had facilitated referrals to assessors and providers, increasing responsiveness and access. As a result, programs had reported more efficient case management, reduced wait times, and improved continuity of care.

We have been able to set up a system with the provincial coordination service that does the referral. So, all referrals come directly to all of us on the team, and then whoever’s available accepts the referral, and I think that has streamlined it.– MAiD assessor and provider

Theme 7: Eligibility assessments

Eligibility assessments and logistics encompass the processes and procedures involved in evaluating patient eligibility and facilitating access to MAiD services.

Sub-theme: Logistics of eligibility assessments

In some jurisdictions, logistical challenges had included limited availability of assessors, providers, and specialists; extended travel distances; scheduling constraints; and difficulties securing transportation for providers.

Finding time to carry out those assessments around our busy schedules is cumbersome … and that is a challenge.– MAiD assessor and provider

Of our communities, 10 of them have less than 200 residents, so ensuring equity of services for folks who want to receive MAiD in their community can be a challenge.– Policymaker

To address these challenges, programs had adopted a range of strategies to improve the accessibility and timeliness of MAiD assessments, particularly in rural or remote areas. These had included reimbursement of travel costs, dedicated coordination services, hub-and-spoke models of service delivery, the formal allocation of clinical hours for MAiD assessments, and the provision of services outside regular clinical hours.

We hired a nurse practitioner up north who’s kind of like a resident MAiD provider in there, which is something we didn’t have before. So, that’s something we really needed because we were adding weeks on to those patients’ wait times just to be able to arrange travel to see them.– Program coordinator

Sub-theme: Virtual assessment methods

Virtual platforms had presented several clinical and technical challenges to MAiD assessments. Clinical challenges had included a limited ability to observe non-verbal cues, assess the patient’s lived environment, build rapport, and ensure privacy and the absence of coercion. Technical challenges had included poor internet connectivity and low digital literacy, especially among older adults or those in rural or remote areas. In addition, the absence of dedicated billing codes for virtual assessments in several jurisdictions had created uncertainty around remuneration, limiting the extent to which virtual assessments had been formally integrated into standard practice.

[on virtual assessments] but you miss out on a lot of body language, you miss out a lot of their environmental context and so it makes it a bit harder to determine eligibility.– MAiD assessor and provider

In contrast, several programs had introduced hybrid models that combined virtual and in-person assessments to address the clinical limitations of virtual assessments. In some settings, family members had played a supportive role in helping patients navigate virtual platforms, particularly where digital literacy was limited. Virtual assessments had also reduced the need for travel, had supported more flexible scheduling, and had enabled providers to conduct a greater number of assessments across a broader geographic range.

We tend to pair up assessments a lot, and we always try to do both virtual and in-person assessments at the same time. It helps the patients, not having to go through the entire interview twice.– MAiD assessor and provider

Sub-theme: Complex case assessments

Participants had described considerable administrative and clinical challenges associated with Track 2 assessments, including extensive documentation, repeat assessments, and coordination and review of multiple specialist consultations. These challenges had been compounded by the medico-legal complexity of Track 2 cases, concerns over professional legal liability, and unease around potential litigation.

The problem we have had is that it takes a long time to complete all the assessments, particularly for Track 2, and to make sure the different specialties have seen the patients. Getting appointments with a specialist is always tricky.– MAiD assessor and provider

We have a very small handful of people who are willing to do Track 2 assessments because they tend to be very time consuming, very complicated, and go way beyond medicine into all of the social determinants of health.– MAiD assessor and provider

Some programs had supported the assessment of complex cases through the implementation of interdisciplinary teams, regular case review processes, and structured follow-up mechanisms for ineligible cases. In some cases, medical directors or experienced providers had facilitated case rounds and had guided decision-making for nuanced Track 2 requests. These strategies had supported consistency in eligibility determinations and decision-making processes.

We have a complex case review where we will take our team and the medical director and do a presentation about what it is about this person’s care that makes them complex. Then, with the medical director’s advice or support, we will assemble a plan to do an assessment.– Program manager

Sub-theme: Conscientiously objecting facilities

Conscientiously objecting facilities had limited access to MAiD services and had created challenges in coordinating care. Logistical difficulties had arisen from urgent patient transfers from these facilities and had negatively impacted the quality and continuity of care, as well as the dignity of patients and families.

And we have to decline people because they’re not safe to transfer. And that’s really hard to tell people that you can’t have MAiD because of where you are, and we can’t move you without it because you don’t want to die in a van. So, we do decline people we don’t think are safe to transfer.– Program manager

I think it’s quite a logistical challenge to move someone to another space, to find the day that works, and then accommodate when they can get there. It’s essentially like admitting them into another place. There’s all this paperwork that goes along with it and it’s a huge nightmare.– Program manager

Some jurisdictions had mitigated these challenges by introducing clear legislative or policy frameworks permitting completion of eligibility assessments within objecting facilities.

One of our successes was getting those objecting sites to agree that everything other than the provision could occur there, because for many years, that was not possible.– Medical director

Theme 8: MAiD provision

MAiD provision encompasses the processes and procedures involved in delivering MAiD to a patient, including access to and administration of medications, as well as ensuring the safety of assessors and providers during provision.

Sub-theme: Medication accessibility

In several jurisdictions, access to MAiD medications had been hindered by limited operating hours, mandatory advance notices, and bureaucratic requirements, such as mandatory hospital admission before medication preparation. In some cases, access to pharmacies had been limited due to conscientious objection from community pharmacies or policies limiting the dispensing of MAiD medications to certain locations such as hospitals. These restrictions had been particularly challenging in rural or remote areas and in urgent cases.

One challenge that I’m dealing with a lot is that we are struggling with having willing pharmacies to dispense medication kits within communities.– MAiD assessor and provider

In contrast, some programs had improved medication access by partnering with community pharmacies, designating central dispensing sites, and establishing delivery processes for remote areas. Some pharmacies had also implemented procedures such as backup medicine kits and pre-filled syringes to reduce preparation time and mitigate problems during administration.

If you need the medication to be sent to you, they would have a bonded courier take them from a bigger facility to that remote facility. It’s a necessary safeguard.– MAiD assessor and provider

Sub-theme: Medication administration

In some jurisdictions, intravenous (IV) medication delivery had been impeded by inconsistent access to supplies and a lack of trained personnel for IV access. This challenge had been pronounced in home-based settings where clinical support was limited.

The nursing availability for IV starts is often a challenge.– MAiD assessor and provider

To address IV access challenges, some programs had arranged for cannula insertion prior to the provision day, had ensured the availability of personnel proficient in IV starts such as nurses or paramedics, and had maintained rosters of skilled staff to support planning.

They have nurses who do IV’s. And I just send them an order, and they usually do it either the afternoon before or the same morning, which works well.– MAiD assessor and provider

Sub-theme: Assessor and provider safety

In some jurisdictions, safety issues had most often arisen during interactions with distressed family members or caregivers who were unsupportive of a patient’s decision to pursue MAiD, especially in home-care settings.

I once had to call the police and say, “Can you escort me? I’m very worried.” This woman was threatening to shoot me and what do I do?– MAiD assessor and provider

In response, some programs had adopted safety protocols to support providers during home-based MAiD care. These had included pre-visit risk assessments and additional personnel in cases where family dynamics or care settings raised concerns.

We also look at the safety of those assessors, and we would never send one person alone to see somebody.– Program manager

Theme 9: Patient and family support processes

Patient and family support encompasses the logistical, social, and psychological support resources provided to patients and families throughout the MAiD process and to families following a MAiD provision.

Sub-theme: Family engagement

Across jurisdictions, HCPs had encountered situations where patient and family perspectives diverged, particularly around whether and when to disclose a MAiD decision or who would be present during provision. These interactions had required careful communication, with some programs noting difficulty balancing confidentiality with the emotional needs of families.

We’ve had cases where the family member was absolutely refusing that the patient proceeds with MAiD.– Program manager

Where programs had dedicated psychosocial support providers and counselling services, these services had supported the resolution of intrafamily conflicts. Multiple meetings could be arranged with patients and/or families. These meetings had provided an opportunity to better understand and carefully reflect on the rationale for their choices, discuss all available options and their potential impact, and arrive at a decision with which they could be at peace.

We have a strong kind of support system through social work for families, patients, and families, but including bereavement, counseling and grief support. So that’s definitely a success.– Medical director

And so, then we work with the patient to support whatever their wishes are, and sometimes we have patients that say, “I don’t want my family knowing that I’m doing this”, so then we’ll push back to them, and say, “well, how do you want your family to find that you’ve died?” We have those kinds of conversations with them, and that’s what I think is the best part of our social workers, they are very well versed in conversations around end of life, and they say those difficult phrases, and they’re invested in having those conversations with patients. So, we would heavily utilize and try to mediate between the family and the patients and try to mend those relationships.– Program manager

Sub-theme: Bereavement and emotional support

In many jurisdictions, MAiD programs had limited integrated or MAiD-specific grief supports available for families, with most programs relying on external non-profit organizations for MAiD-specific bereavement support. A lack of culturally sensitive bereavement services, particularly for Indigenous families, presented additional challenges in accessing appropriate emotional care.

I mean there’s recognition that bereavement is something we need to support. But the resources are very thin.– Specialist

Some programs had used social workers and/or spiritual care providers who were integrated into the MAiD team to provide dedicated grief and bereavement support. Programs had also collaborated with community organizations and institutional partners to provide culturally and contextually appropriate grief services.

I would say a large part of what makes us successful has nothing to do with the medical aspect of things; it has to do with the psychosocial aspect of things.– MAiD assessor and provider

Theme 10: Support for MAiD assessors and providers

Support for MAiD assessors and providers encompasses the professional, logistical, and emotional supports required to enable and sustain practitioner participation in MAiD service delivery.

Sub-theme: Operational supports

In several jurisdictions, MAiD programs had faced challenges related to the inadequate remuneration for assessments and provision, restrictive or unclear compensation structures for nurse practitioners, and limited access to administrative and travel-related support. The cumulative effect of these factors had given rise to concerns about burnout, workforce sustainability, and the retention of assessors and providers, particularly in rural regions.

Compensation at the moment is one of them. That’s a fairly strong challenge. The fee for service rate is not competitive with the current pay scale that a family physician can earn if they sit in their office doing office work.– MAiD assessor and provider

In some jurisdictions, billing codes, travel funding, and formal coordination supports dedicated to MAiD services had been introduced to reduce logistical and administrative demands on providers. Program coordinators had assisted with scheduling and travel arrangements, and designated compensation mechanisms had covered time spent on assessments, documentation, and travel. These measures had supported provider participation in MAiD services and had improved consistency in service delivery.

We’re compensated for all of the time filling out the forms ahead of time and traveling to the community and everything. That’s all compensated, which I think is important and fair, and what needs to be done for people to do this work.– MAiD assessor and provider

Sub-theme: Mental health supports

The delivery of MAiD services had been widely recognized to be emotionally demanding for staff members; however, many programs had lacked formal mental health and well-being supports for staff.

Right now, we do not have any official debriefing process in place. We do not have any sort of process in place following, you know, an especially difficult provision or a time out to sort of collect yourself. We just do not have that built into our process at all, and I find that is really like morally distressing.– MAiD assessor and provider

In some jurisdictions, programs had offered access to general or MAiD-specific counselling services to support staff involved in MAiD services. Regular debriefing sessions and peer reflection opportunities had also been implemented in some settings following complex or emotionally challenging cases. Where formal support was not available, providers had relied on informal coping strategies, including peer support groups, trusted colleagues, local communities of practice, and professional spaces such as CAMAP forums.

We have built into our team social workers, and we do a kind of debrief with each other as a team. And we do a reach out to all of the external nurses and social workers and meet monthly with an Employee Assistance Program.– Medical director

Discussion

This study examined the barriers to and facilitators of MAiD service delivery in Canada from the perspectives of professionals across roles and jurisdictions. The findings highlight both common and novel challenges, along with the strategies developed to address them. The findings are organized across system-level, operational, and support dimensions of service delivery, offering a structured account of MAiD that may inform the adaptation of MAiD programs in Canada and the design of assisted dying services internationally.

Several themes identified in our study have been well documented across Canadian and international literature. These include MAiD service delivery support systems; program coordination and oversight mechanisms; documentation, reporting and information management systems; and professional training and development procedures. Reported challenges included high workloads [10–13, 15, 16, 20–22, 26, 27], limited collaboration and coordination with other services or institutions [7, 11, 13–17, 20, 24, 25], and a lack of dedicated MAiD training or education [7, 8, 11, 13–16, 19, 22, 23, 25, 26]. The literature also documented facilitators such as supportive leadership [15, 17], robust centralized coordination services and interprofessional supports [8, 15–17, 21, 22, 24, 25], and the availability of MAiD-specific curricula from CAMAP and health authorities for assessors and providers [22, 23].

Several other themes are less frequently reflected in the literature, including public awareness and education; referral, coordination, and screening processes; eligibility assessments; and support for MAiD assessors and providers. These include concerns about misinformation regarding MAiD and its processes among the public and other HCPs [8, 14, 16, 17, 21, 26], complexities surrounding coordination and unclear or overlapping roles among MAiD program staff [7, 15, 16, 20, 21, 24–27], the challenge of navigating conscientiously objecting HCPs and non-participating facilities [4, 8, 12–15, 20, 27], and inadequate financial compensation [11, 21, 22, 27]. Reported facilitators include centralized coordination services, standardized documentation and processes [8, 15, 17, 21, 22, 25], and MAiD-specific or general mental health supports for assessors and providers [9, 12, 19, 21, 24].

Themes related to MAiD provision and patient and family support processes are scarcely reflected in the existing literature. Prior studies have touched on the logistics of acquiring and transporting medications [14], the need for stronger bereavement support for patients and families [21], and issues with medication administration [14, 26]. To our knowledge, however, no published work has addressed the challenges we identified concerning virtual assessments, electronic medical records, or healthcare provider safety. Similarly, the facilitators described by our participants, such as simultaneous hybrid assessments, expanded access to electronic medical records, and safety protocols, have not been reported in previously published work. These barriers and facilitators represent emerging areas of concern and innovation within MAiD service delivery and warrant dedicated investigation.

Some barriers to and facilitators of service delivery appeared across several themes. Conscientious objection affected multiple stages of service delivery. Participants described forced transfers from objecting facilities as logistically difficult (Theme 7), difficulty obtaining referrals and information from objecting HCPs (Theme 6), and inaccurate information being shared with patients by objecting HCPs (Theme 4). Track 2 cases similarly posed challenges across service delivery. Participants described the complexity of cases as exacerbating challenges related to workforce capacity (Theme 1), coordination and case management (Theme 6), and inadequate compensation for taking on Track 2 cases (Theme 10). Challenges for Indigenous patients and families spanned several themes. Participants described limited culturally appropriate information about MAiD (Theme 4), a shortage of bereavement services suited to Indigenous communities (Theme 9), and geographic barriers to access in rural and remote areas (Themes 6 and 7). Centralized coordination services supported the continuity and timeliness of care (Theme 2), reduced documentation burden on assessors and providers (Theme 10), increased accuracy of reporting (Theme 3), and helped disseminate consistent information to patients and professionals (Theme 4). Integrated social work, spiritual care, and psychosocial support services supported family engagement and bereavement care (Theme 9) and provided mental health support for assessors and providers (Theme 10).

Our findings and the existing literature show that Canadian MAiD programs rely on both systemic supports and the dedication of the professionals who deliver the service. Programs with early planning and dedicated funding established interdisciplinary MAiD teams, centralized coordination, integrated psychosocial and bereavement services, and MAiD-specific training. In these programs, responsibilities were shared across roles. Where such supports were limited, assessors, providers and coordinators expanded their workload to sustain services. This concentration of responsibilities was particularly visible in Track 2 assessments, which a small number of providers absorbed, and in coordinating care around conscientiously objecting facilities, which added logistical burden to providers and coordinators. Many professionals carried out MAiD tasks alongside their other clinical duties, absorbing responsibilities such as following up with referring care teams, completing documentation without administrative assistance, and navigating complex family dynamics without integrated social work. Alongside these operational demands, MAiD work carried emotional and moral weight throughout the service delivery process. Many clinicians described a lack of MAiD-specific emotional support in their practice and developed their own communities of practice and informal peer relationships in response. Across these conditions, the dedication of professionals sustained services where systemic, operational, and support-related processes faltered against growing demand.

Since MAiD was legalized, case volume has grown rapidly, and Track 2 assessments have introduced additional clinical, administrative, and medico-legal complexity. In this context, Canadian programs are preparing for the 2027 expansion of MAiD to persons whose sole underlying medical condition is a mental illness [3], which will further increase volume and complexity. Programs that have the system-level and operational supports already in place are better positioned for this expansion. Programs that currently rely on individual clinician capacity will face greater strain. The same distinction applies to international jurisdictions that are legislating or implementing assisted dying. Our findings identify the areas where early investment strengthens service delivery. System-level investments include dedicated funding, centralized coordination, interoperable electronic medical record (EMR) systems, and MAiD-specific training. Operational investments include standardized referral pathways and interdisciplinary case reviews. Support-level investments include integrated psychosocial and bereavement services for families, and dedicated mental health supports for clinicians.

Strengths and limitations

The study draws on a diverse sample of MAiD professionals, including clinician, support, and policy roles from across Canada. However, the use of purposive sampling with self-selecting participants may limit the generalizability of findings. Subgroup differences were not reported and could be an area for future research.

Conclusion

This study identified both persistent and emerging barriers to MAiD service provision in Canada, including workforce and compensation pressures, limited coordination with other services, misinformation regarding eligibility, inadequate bereavement supports, and challenges related to medication access and transport. At the same time, participants described important facilitators, including centralized coordination systems, standardized documentation, interprofessional collaboration, and supportive leadership.

Together, these findings highlight that improving MAiD service delivery requires more than individual provider commitment. System-level investments are needed in education, coordination infrastructure, workforce supports, medication logistics, and family support pathways. Strengthening these areas may improve the consistency, accessibility, and sustainability of MAiD services across Canada.

Recommendations

Based on these findings, key recommendations include strengthening public and provider education regarding MAiD eligibility, expanding standardized training and organizational supports for assessors and providers, improving centralized coordination and documentation processes, addressing medication procurement and transport barriers, and developing more consistent bereavement supports for families affected by MAiD.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 ^{(1.6MB, docx)}

Abbreviations

MAiD

Medical Assistance in Dying

EMR

Electronic Medical Record

HCP

Healthcare Professional

CAMAP

Canadian Association of MAiD Assessors and Providers

Author contributions

AQ contributed to data synthesis, thematic analysis and narrative synthesis. TS is the corresponding author and the project lead for the larger MAiD project. They provided guidance on project direction, analysis, and writing. DM provided extensive guidance throughout the project and reviewed and edited the manuscript. All authors have read and approved the final manuscript.

Funding

This study is part of a larger project on MAiD service delivery in Canada funded by Health Canada (#2223-HQ-000267).

Data availability

The datasets generated and/or analysed during the current study are not publicly available in order to respect the wishes of privacy of our participants but are available from the corresponding author on reasonable request.

Declarations

Ethics approval and consent to participate

The study was approved by the University of Alberta Health Research Ethics Review Board (Pro00129886) and in accordance with the Declaration of Helsinki. In addition, ethics approval was obtained from several regions, provinces and territories that required that the review receive approval from their own ethics committees or boards. Written and informed consent was obtained from all participants.

Consent for publication

Consent for publication is not applicable.

Competing interests

The authors declare no competing interests.