In 2021, Canada revised its medical assistance in dying (MAiD) legislation by passing Bill C-7, which broadened the eligibility criteria to include individuals whose natural death is not reasonably foreseeable (Track 2). These cases involve individuals with incurable and severe conditions who experience significant suffering but are not approaching death. Track 2 tests include additional protective measures and require complex clinical decision-making. The purpose of this study was to explain how MAiD assessors determine eligibility for Track 2 applicants and how they interpret the most important legal and ethical standards in practice. Â
This qualitative study employed an interpretive description approach to produce practical clinical implications. Semi-structured virtual interviews were conducted between April 2024 and March 2025 with physicians and nurse practitioners who had evaluated Track 2 MAiD applicants. Participants were recruited through convenience, snowball, and purposive sampling across four Canadian provinces. Interviews lasted approximately one hour, were audio recorded, transcribed, accuracy checked, and analyzed thematically using constant comparative analysis with NVivo software, aiding data organization. The study received ethics approval from the University of British Columbia research ethics board, and all participants provided informed consent.Â
Twenty-three assessors participated, comprising 14 physicians and 9 nurse practitioners. Of them, 56% were female, 70% were aged 45 years or older, and 70% had experience with over 6 Track 2 cases. Participants described Track 2 assessments as relational, careful, and time-intensive. Building trust and understanding applicants’ life stories was considered essential for assessing suffering, capacity, and voluntariness. Assessors did not consider general knowledge, but decision-specific capacity; they generally assumed capacity unless demonstrated otherwise. Determining whether applicants qualified for Track 1 or Track 2 was often complex, with assessors relying on clinical judgment rather than strict timelines, which ranged from six months to five years under pressure, evaluating whether suffering was irreducible involved reviewing prior treatments, access barriers, and applicants’ perspectives on what constituted reasonable care.Â
The 90-day assessment period was usually extended well beyond the statutory timeframe, sometimes lasting up to a year or longer. Assessors indicated spending 5-20 hours per case. In most cases, specialist consultations were frequently needed, but not always easily accessible. The consultations with peers or in a team were greatly appreciated for supporting decision-making, maintaining consistency, and safeguarding the assessor’s well-being. Identifying ineligible applicants was especially stressful, with concerns about patient distress, risk of suicide, and potential litigation. Overall, Track 2 MAiD assessments were described as legally and ethically complex and requiring substantial clinical interpretation of legislative language, including concepts such as “reasonably foreseeable natural death” and “reasonable means of alleviating suffering.”
Assessors reported using a relational autonomy framework, considering relationships with patients, their life circumstances, and social conditions alongside medical realities. This approach aligns with Canadian MAiD jurisprudence and supports respectful, autonomy-centered decision-making while helping define vulnerability. Nonetheless, the differences in the interpretation across regions and assessors raise concerns about equity. The participants raised the importance of mentorship, common guidance, and formal case consultation to improve the calibration of practice. Â Limited access to specialists and disorganized health records further complicated assessments.
Overall, Track 2 MAiD evaluations involve extensive interpretation, critical assessment, and ongoing interaction with the applicants. Assessors are committed to conducting comprehensive, humane assessments grounded in a relational autonomy approach; however, challenges remain due to variability and professional isolation. Greater consistency and equity could be achieved by expanding funded interdisciplinary case consultation models, enhancing access to specialist input, and promoting ongoing calibration among assessors across regions.
Reference: Pesut B, Thorne S, Sharp H, et al. Assessors’ decision-making regarding applicant eligibility for Track 2 medical assistance in dying in Canada: a qualitative study. CMAJ. 2026;198(1):E1-E9. doi:10.1503/cmaj.251071Â
