Abstract
<title>Abstract</title> <p>Background: Although Medical Assistance in Dying (MAiD) is legal in Canada with established safeguards, it remains a complex and often contested issue with significant barriers to patient access. However, professional obligations on the requirement for an effective referral differ by province and regulator in Canada leading to some providers denying MAiD services or referrals based on their personal beliefs. Methods: We conducted 28 semi-structured in-depth interviews with patients or their family members who had been refused MAiD services since its legalization, to document their experiences with denial. Results: Participants reported that refusing providers frequently cited ineligibility, which they perceived as reflecting narrow interpretations of the eligibility criteria. Their multiple coexisting illnesses resulted in cumulative suffering, which they felt was not understood appropriately even though intolerable suffering is one of several requirements for MAiD. Denials also stemmed from systemic barriers in application and approval processes, lack of decisional capacity, mental illness as the sole underlying medical condition (MI-SUMC), and institutional or provider refusals rooted in religious beliefs or personal discomfort. These denials led to emotional distress, disempowerment, and increased suffering for patients and families. Participants recommended clearer policy guidance and consistent implementation, legalization of advanced requests, inclusion of MI-SUMC, capacity building and training for health professionals, and requirements ensuring providers fulfill their obligations. Conclusions: As MAiD legislation and policy continue to evolve in Canada, it is essential to address these barriers to access to ensure that patients receive the services to which they are entitled in a patient-centred and timely manner.</p>