The scoping review will be conducted following the Joanna Briggs Institute methodology for scoping reviews and reported in accordance with the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines [28,29]. The scoping review will follow these steps: (1) translating the overarching objective of the study, which is to better understand the use of MAiD in Québec, into an operationalized research question, formulated to make the population, concept, and context explicit; (2) specifying inclusion and exclusion criteria; (3) in collaboration with a librarian, developing the strategy to identify relevant literature, with adaptation for 10 databases (eg, MEDLINE, CINAHL, Embase, PsycINFO, Web of Science, and gray literature); (4) conducting the selection and extraction through Covidence (Veritas Health Innovation) [30] by 2 independent reviewers; (5) presenting the findings in a narrative format, and mapping them in tables and graphs to address the review objectives; and (6) drafting recommendations and implications for research and practice in a language adapted to different target audiences (general population, decision-makers, and practitioners), and identifying future research needs.

In this section, we will present the 5 themes that structure the call for proposals and their associated specific methods. For the sake of consistency, we have chosen to present them in accordance with the Bronfenbrenner ecological systems theory, from the microsystem (eg, personal characteristics) to the macrosystem (eg, practices, legislation, and public policies) as presented in Figure 1.

This theme focuses on the personal characteristics of people who have requested MAiD, using qualitative methods to help understand the process that led to their request.

We will conduct interviews inspired by narrative approaches of the “life story” [52-55] with approximately 30 people who have requested MAiD, diversifying the choice of participants according to their personal characteristics (age, gender, identity, cultural or ethnic origin, diagnoses, disability status, and socioeconomic situation).

A semidirective approach will be used to focus on the stories collected, while directing them toward the central themes, encouraging the emergence of new reflections. One or two interviews will be conducted with each participant (varying in length from 30 to 60 minutes, depending on the participant’s health and ability to participate). The interviews will be recorded and transcribed integrally. Interviewers will keep a diary in order to note their impressions following each interview and use this information to enrich their analysis (emotional state of the participant, nonverbal cues during the interview, general context of the interview, etc). Recruitment will be based on the CIRAMM’s contacts across the province (MAiD interdisciplinary support groups [ISGs], hospice care organizations, patient associations, etc) with the aim of reaching participants in different regions of Québec (urban, semiurban, and rural). During recruitment, we will explore the possibility of involving one of the participant’s close-ones, as well as one of their care providers, in order to conduct a triadic case study (see “Case Studies of Triads” section below).

A thematic analysis of the data [56,57] will be conducted according to the following steps: (1) interview verbatims and diaries will be read, (2) a sample of 3 transcripts will be randomly chosen and analyzed to produce a list of themes, and (3) the content of the remaining interviews and diaries will be classified from this list of themes using NVivo software (version 14; Lumivero; released in 2023). The quality of the codification process will be ensured by an interjudge agreement process in accordance with validity and quality criteria in qualitative research [58].

Many studies [59,60] focus on the individual perspectives of people who want to receive assistance in dying, their relatives, or caregiving staff. This approach does not reveal the relational dynamics at play within a request, the contrasts between different individual perspectives, and the way these factors influence each individual’s perspective.

To overcome the shortcomings identified in current literature, we will carry out 10 triadic case studies, each comprising “contextualized narrative” interviews with the person requesting MAiD, one of their close-ones, and one of their care providers (doctor, nurse, allied health clinicians, care assistant, etc). This method was tested in another study conducted in the Netherlands by a coleader of this theme and her colleagues [61]. A different interview guide will be used for each subgroup, aimed at gaining a better understanding of the personal factors that motivate people to request MAiD from the perspective of the 3 subgroups. Each person will be interviewed individually.

An analysis anchored in phenomenology, combining a longitudinal and multiperspective framework [62], as well as different aspects of reflective lifeworld research [63], will be used [62,64,65]. The whole process will be iterative and guided by multiple discussions between the members of our research team [66].

The researchers will also undertake a retrospective chart review of MAiD requesters in a single institution in Montréal. The purpose of this study is to better understand the role of economic disadvantage (which is defined as dependence on social assistance as one’s sole form of revenue) on these individuals’ MAiD requests, particularly for those requesters whose natural death is not reasonably foreseeable (Track 2), as it is this group where public debate about the impact of economic disadvantage on requests has arisen. This part of the protocol draws upon similar methods used in 2 studies currently being carried out by CIRAMM researchers, the first involving a population of requesters in which the assessment required a psychiatric consultation [67], the second involving people with amyotrophic lateral sclerosis [68].

We aim to review the charts of all Track 2 requesters from 2021 to 2025 who are experiencing economic disadvantage. We will obtain a list of all requesters at the identified institution. We will then do a preliminary review to determine the economic situation of each requester, identifying those in a situation of economic disadvantage. The charts of this subgroup will be subject to a complete chart review. First, we will extract data relating to each individual’s sociodemographic profile: age, gender, social circumstance, diagnoses, stated reason for requesting MAiD, and whether MAiD was ultimately received. Second, we will review all notes pertaining to the person’s request for an assisted death. We will extract all segments that refer to the person’s statements about assisted dying, as well as the writer’s views about those statements, if any. We will be particularly attentive to any notes relating to the person’s economic situation and its potential impact on the experience of their disease, access to care, and suffering. In our analysis, we will focus on the manifest content of the extracted text. We will identify meaning units from the extracted segments, grouping them together in categories. Ultimately, we will seek patterns that link the categories, which describe and explain the role of a person’s economic circumstances in their request for an assisted death, with their sociodemographic profiles, recognizing that a plurality of such narratives may emerge from these records [69].

For this theme, we adopt a systematic comparison approach between Québec regions to examine the relationships between gaps in the use of MAiD and differences in sociodemographic profiles, in health services structures, practices, and perceptions. Québec regions will be further broken into territories corresponding to each of the 30 MAiD ISGs.

A mixed methods approach will be implemented, including a document analysis and system mapping. Qualitative discourse analysis will be used to summarize government reports on MAiD (provincial and regional) and information documents available to the public, to explain how MAiD is presented and how resources are promoted in each region. Correlational analysis from MAiD reports and regional sociodemographics will be used to explore the strength and direction of links between regional MAiD rates and the social profile of the population. Both qualitative and quantitative results will be mobilized for a system mapping analysis to show possible causal loops between different categories of items.

Document analysis is a systematic procedure for reviewing and synthesizing various sources (printed or digital), including their format dimensions (institutional authors, aims, and availability), and their discourse (themes, perspective, posture, and legitimation).

We will first create a mixed database of organizational documents, records, and reports produced by the ISGs on cases of refused, accepted, abandoned, and administered MAiD requests for the period 2019-2025 (case profiles including age of individuals, status of request, trajectory characteristics, access to alternative curative, palliative, and psychosocial care and services). Data gathered by the Québec End-of-Life Commission (Control Commission) will be considered, as well as sociodemographic data by region (population, age, socioeconomic profile, disease incidence, deaths, and causes of death, including rates of unassisted suicide). Other documents from gray literature will also be analyzed (local reports and registers of care and services from the ISGs, the End-of-Life Commission, and the Ministry of Health and Social Services, information and training documents, etc).

In order to produce a general portrait of the evolution and current state of structures, resources, and practices in each region, the qualitative data will be subject to a documentary analysis using the read, extract, analyze, and distill method [70]. Quantitative data will be the subject of descriptive and comparative statistical analyses of regional realities and their evolution (averages, frequencies, and SDs), population representativeness of cases, as well as correlation analyses between the explanatory variables and the rate of increase in MAiD use. The analysis of the proportionality of the variables for each region will be used, among other things, to determine the associations and the relative weight of population aging in the use of MAiD, which is the main assumption made in the CSFV report [4].

This theme encompasses 2 methods. First, media coverage analysis can provide access to the discursive and symbolic predominance of MAiD and, in doing so, shed light on how content contributes to ways of thinking, feeling, and acting about MAiD, and how we integrate it into our “own social value systems” [76]. Second, community forums (CFs) favor an open, participatory approach with citizens and take the pulse of the community’s concerns, knowledge, and resources [77,78]. In addition to stimulating the exchange of ideas, this dynamic method brings together people from various backgrounds in a given region to hear and gather their opinions on a subject that concerns them, such as the use of MAiD.

Legal databases (eg, Société québécoise d'information juridique, Centre d'accès à l'information juridique, and La Référence for Québec; Canadian Legal Information Institute for the rest of Canada; and Lexis, Westlaw, and HeinOnline for selected international jurisdictions) will be searched to identify legal documents associated with MAiD legislation for the jurisdictions selected. The comparative positivist legal analysis (legislation, case law, and doctrine) carried out by our team of legal experts will enable us to identify the differences and similarities between laws and the scope of legislative criteria, and to grasp the appropriateness of their interpretation by contrasting them with the findings emerging from the scoping review. This work will be complemented by a comparative analysis of Québec public policies promoting the quality of life of sick people and their families (eg, home care [82] and informal care [83]), as well as of the various legal mechanisms contained in the Québec legislation (MAiD, advance directives, palliative care, and continuous palliative sedation), while considering recent updates to the law. In addition, by compiling (and critically comparing) data from 2 complementary sources [84], we will be able to address “Examine how MAiD numbers in Québec compare to those in other jurisdictions” objective, which is to examine how MAiD numbers in Québec compare to those in other jurisdictions: (1) the annual reports of the Control Commissions of the selected jurisdictions based on official MAiD declarations, and (2) independent surveys conducted in certain jurisdictions and aimed at documenting the frequency of MAiD practices, in addition to other types of end-of-life medical practices [85,86].

The final objective of Theme 4 (Textbox 1 [Explore how Québec’s context can explain differences in MAiD use]) represents one of the overarching goals of the project, requiring the consideration of all results generated across themes, through both cross-thematic and theme-specific methods. To this end, we will draw on the realist synthesis method developed by Pawson et al [87]. The realist synthesis method addresses questions concerning what works for whom, in what circumstances, in what respects, and how a complex social intervention operates, such as a public policy, a health care system, or even a law [87-89].

Realistic synthesis is characterized by (1) the use of a conceptual framework and (2) the involvement of an advisory committee at various stages of the process. The conceptual framework chosen will combine the Bronfenbrenner ecological systems theory and that of the Health System Performance Measurement [90]. It will be adapted to the phenomenon under study (use of MAiD) and will provide a global understanding of the explanatory factors and the underlying mechanisms. In particular, the framework will consider (1) the characteristics and inputs of the legislation (macrosystem) and its operational functioning (2) the characteristics and social determinants of health related to individuals (microsystem) who use MAiD, (3) the outputs of the system (exosystem), which include access to and provision of MAiD and associated services, and (4) the results obtained (the use of MAiD in terms of requests and provisions). We will add the historical context (chronosystem) as a potential explanatory factor for the differences observed in the evolution of the use of MAiD (eg, legislative change initiated by whom and how).

A bipartite advisory committee will be set up, made up of (1) members of an international advisory committee and (2) representatives of the stakeholders (patients and their families, physicians, nurse practitioners, and other health care professionals, managers, and decision-makers) involved in MAiD in Québec. The involvement of the bipartite advisory committee will be particularly decisive in adapting the conceptual framework to the specific characteristics of the MAiD study, as well as in interpreting the results. The comparison of our data, based on the conceptual framework, will enable us to identify the contributing factors for which data already exist, as well as those for which further studies are required.

On June 7, 2023, Québec’s Act respecting end-of-life care was modified to allow AR-MAiD from people diagnosed with a disease leading to decisional incapacity [2]. Legal dispositions related to AR-MAiD came into effect on October 30, 2024. AR-MAiD may lead to further increases in the use of MAiD, given its widespread acceptability in Québec [26,33,91]. On the other hand, providing MAiD to patients who are no longer competent, based on their advance requests, can be challenging to implement. To inform the implementation of the AR-MAiD regime in Québec, a comparative analysis of the legal regimes of jurisdictions that already allow such requests and a systematic review of implementation challenges will be conducted.

A comparative portrait specific to AR-MAiD will be drawn from the legal analysis conducted under Theme 4. Results will highlight processes that led to AR-MAiD legalization in permissive jurisdictions and reasons underlying different legislative choices pertaining to eligibility criteria, procedural safeguards, and the assessment of suffering. Professional standards established by medical associations, learned societies, and regulatory bodies will complement our legal interpretation work [92]. Legal analysis specific to this theme will be anchored in a recent review of Dutch and Belgian AR-MAiD legislation [92], which we will extend to include Luxembourg, Colombia, Spain, and Québec.

We aim to provide a comprehensive overview of international literature on the barriers and facilitators (both anticipated and experienced) related to AR-MAiD. Perspectives from patients, their relatives, health care professionals, legal experts, and scholars will be sought. Primary studies (qualitative, quantitative, and mixed methods studies), theoretical work, as well as relevant documents from gray literature (eg, theses and Control Commissions’ reports) will be considered for inclusion. Peer-reviewed studies published after 2002 will be searched by a librarian in 10 electronic databases, with no restriction on language or origin of the authors. Screening of retrieved citations, assessment of the methodological quality of included studies, and data extraction will be conducted independently by pairs of researchers, supported by the software Covidence [30]. A preliminary search for publications on AR-MAiD revealed a predominance of qualitative studies, with a few surveys and mixed methods studies [93-95]. Hence, to enable synthesis and integration, quantitative data will be transformed into themes and subthemes in a convergent integrated approach. Identified barriers and facilitators to implementing AR-MAiD will be summarized following a content analysis of included documents, examined in light of the Québec regime, and contrasted according to (1) whether they are anticipated or truly experienced, (2) the perspective from which they originate (eg, that of health care professionals or relatives), (3) when they might arise along the MAiD process (request drafting, eligibility assessment, or MAiD provision), and (4) prevailing legislation and codes of practice. We expect our legal analysis and systematic review to highlight significant challenges to implementing AR-MAiD in Québec and also possible ways to overcome them.