ADVANCE MAiD REQUEST BEFORE DIAGNOSIS– EXAMPLE FORM

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1. Personal Information

Full Legal Name: ___________________________________________
Date of Birth (YYYY/MM/DD): _______________________________
Address: _________________________________________________

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2. Purpose of This Form

I am completing this form to record my advance wishes for Medical Assistance in Dying (MAiD) in the event of intolerable suffering due to cognitive decline or other irreversible conditions that prevent me from making or communicating decisions in the future.

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3. Statement of Intention

I am signing this form voluntarily, free from any pressure, threat, or undue influence.
I understand what MAiD is and the medical implications of my choice.
I do not wish to have my life prolonged if the person I was is no longer present.

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4. Situations Where I Would No Longer Want to Continue Living

(Check all that apply)

Cognitive Awareness

☐ Permanent inability to recognize close family or friends
☐ Complete disorientation to time, place, and situation that does not improve
☐ Irreversible loss of personality, values, or behaviors that define who I am
☐ Inability to remember my own name or personal history
☐ No awareness or response to surroundings, people, or events
☐ Permanent inability to follow even simple instructions
☐ Confusion most of the time, with only brief moments of clarity
☐ Unable to learn or remember new information

Personal Dignity

☐ Complete dependence on others for all toileting, feeding, bathing, and dressing
☐ Inability to swallow food or liquids safely, requiring long-term tube feeding
☐ Bedridden and unable to move or reposition myself without assistance
☐ Loss of bladder and bowel control with inability to maintain personal hygiene
☐ Requirement for constant physical restraints or heavy sedation to prevent harm
☐ Ongoing foul odour or uncleanliness due to inability to maintain hygiene
☐ Severe contractures (permanent muscle tightening) causing deformity and pain
☐ Reliance on invasive medical devices (catheters, feeding tubes, ventilators) with no possibility of recovery
☐ Unable to get out of bed or chair without help
☐ Requiring full assistance for eating or drinking

Communication & Connection

☐ Total inability to communicate in any way (verbally, in writing, or with gestures)
☐ No ability to understand or respond to familiar voices, faces, or touch
☐ No ability to form or maintain emotional bonds with family or friends
☐ Appears withdrawn, vacant, or unresponsive most of the time
☐ Complete inability to express pain, fear, or needs to caregivers
☐ No participation in any activities, hobbies, or personal interests
☐ Rarely speaks or responds in conversation
☐ Speaks but without meaning or relevance to surroundings

Suffering

☐ Ongoing, unrelieved physical pain despite maximum medical treatment
☐ Severe breathing difficulties or constant shortness of breath
☐ Frequent, severe infections (e.g., pneumonia, urinary tract) causing repeated suffering
☐ Severe weight loss or malnutrition despite assistance
☐ Persistent skin breakdown or pressure sores causing significant pain and infection risk
☐ Frequent, exhausting hospital admissions with no meaningful recovery
☐ Constant fear, confusion, or agitation that cannot be eased
☐ Persistent crying, moaning, or yelling due to distress or discomfort
☐ Involuntary movements, spasms, or rigidity that cause constant discomfort
☐ Severe restlessness or pacing without purpose, causing exhaustion or injury
☐ Dependence on repeated emergency interventions with no lasting benefit
☐ Nausea or vomiting that cannot be controlled
☐ Fatigue so severe it prevents participation in daily life

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Other: ______________________________________________
Other: ______________________________________________

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5. Threshold for Action

If ______ or more of the above conditions are present at the same time, I request my Advance MAiD Request be honored once legal and medical criteria are met.

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6. Final Safeguards

• MAiD cannot proceed until laws allow advance consent.

• Two physicians or nurse practitioners must confirm my condition meets legal criteria.

• My substitute decision-maker must be consulted if I cannot speak for myself.

• If I appear peaceful, joyful, or emotionally connected despite meeting the above criteria, the decision must be reviewed again before proceeding.

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7. Personal Statement (Optional)

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8. Spiritual or Cultural Beliefs (Optional)

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9. Signatures

Signature of Person Making This Request:

Signed: _________________________  Date: _______________

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Witnesses (Two Required)

Rules:

• Not related by blood, marriage, or adoption

• Not a beneficiary of my estate

• Not directly involved in my healthcare

• No personal or financial interest in my death

• Once legal, coercion or undue influence will be a criminal offence

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Witness #1 Name: __________________________
Signature: __________________________ Date: __________________

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Witness #2 Name: __________________________
Signature: __________________________ Date: __________________

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Healthcare Professional Verification (Optional until law changes - will be required once legally recognized)

I confirm I met privately with the person named above, determined they had decision-making capacity, understood the nature and consequences of this request, and were acting voluntarily without coercion.

Name & Credentials: __________________________
Signature: __________________________ Date: __________________

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10. Review or Expiry (Optional)

☐ Remain valid until revoked by me.
☐ Expire and be reviewed on or before: ____________ (YYYY/MM/DD).

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11. Reaffirmation Log (Optional)

Date                        Signature                              Notes

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