Early Experience With the California End of Life Option Act: Balancing Institutional Participation and Physician Conscientious Objection

Because it was new: Unexpected experiences of physician providers during Canada's early years of legal medical assistance in dying

Implementing newly legalized euthanasia or assisted dying presents challenges. The procedure is high-stakes and irreversible and the context is controversial and associated with high emotions and strong opinions. This qualitative study reports unexpected experiences of twenty-one medical doctors who provided Medical Assistance in Dying (MAID) in the first years after legalization in Canada. The phrase 'because it was new' occurred multiple times as doctors attributed unanticipated experiences to the lack of individual and collective experience or knowledge. Positively viewed surprises included increased awareness of palliative care and an unexpected personal sense of fulfillment from helping others. Negative surprises were attributed multiple factors including ambiguously phrased legislation, systems issues and individual inexperience. Participants described issues such as technical difficulties around provision, provider anxiety, logistical snags and inability to adequately counsel and guide families. Participants expressed desire for more guidance, mentoring, training, and team communication. This article draws on phenomenological analysis of data to present providers' accounts of their experiences in the Canadian context. This will assist new providers and jurisdictions in anticipating and preparing for circumstances that were unexpected for the first cohort.

What the Doctor Would Prescribe: Physician Experiences of Providing Voluntary Assisted Dying in Australia

BACKGROUND

Like many countries where voluntary assisted dying (VAD) is legal, eligible doctors in Victoria, Australia, have sole legal authority to provide it. Doctors' attitudes towards legalised VAD have direct bearing on their willingness to participate in VAD and consequently, on whether permissive laws can effectively facilitate access to VAD. The study aimed to explore how some Victorian doctors are perceiving and experiencing the provision of legalised VAD under a recently commenced law.

METHODS

Semi-structured interviews with 25 Victorian doctors with no in-principle objection to legalised VAD were conducted between July 2019-February 2020. Interviews were recorded, transcribed, and analysed using thematic analysis. Ethical approval from the relevant institution was obtained.

RESULTS

Doctors perceive or experience VAD to fundamentally challenge traditional medical practice. Barriers to access to VAD derive from applicant, communication, and doctor-related factors. Doctors' willingness to participate in VAD is situation specific.

Should Institutional Conscientious Objection to Assisted Dying be Accommodated?

The contentious, topical debate about whether faith-based health care organizations should be granted accommodation on the basis of institutional conscientious objection to medical assistance is dying (MAiD) is addressed through a comparative analysis of arguments on both sides of the issue that references such relevant considerations as: claimed ‘moral-authority’, competing rights-based claims, obligations arising from patient welfare principles, formal justice, dissimilarity in consequences, and two illustrative arguments from analogy. The analysis leads to the conclusion that nonconditional accommodation on the basis of institutional conscientious objection to MAiD is not ethically acceptable in Canada. A compromise mechanism, consisting of a suggested set of pragmatic conditions, is proposed that could effectively balance the competing moral responsibilities that arise from this conclusion and a core assumption of the paper, i.e., that some dominant faith-based health institutions can legitimately request, and expect, that provincial/territorial governments pay them a measure of respect in their operational, health-care-delivery decision making because of these institutions’ long history of providing high quality, health care in Canada. It is further suggested that provincial/territorial governments only allow large, publicly funded, faith-based health care organizations to enact a conditional version of accommodation on the basis of institutional conscientious objection to MAiD in circumstances where the organization has entered into a formal agreement with the relevant health department to meet the proposed, compromise conditions (or a relevantly-similar set of conditions).

Conscientious participants and the ethical dimensions of physician support for legalised voluntary assisted dying

The Australian state of Victoria legalised voluntary assisted dying (VAD) in June 2019. Like most jurisdictions with legalised VAD, the Victorian law constructs physicians as the only legal providers of VAD. Physicians with conscientious objection to VAD are not compelled to participate in the practice, requiring colleagues who are willing to participate to transact the process for eligible applicants. Physicians who provide VAD because of their active, moral and purposeful support for the law are known as conscientious participants. Conscientious participation has received scant attention in the bioethics literature. Patient access to VAD is contingent on the development of a sufficient corpus of conscientious participants in permissive jurisdictions. This article reports the findings of a small empirical study into how some Victorian physicians with no in-principle opposition towards the legalisation of VAD, are ethically orientating themselves towards the law, in the first 8 months of the law's operation. It finds that in-principle-supportive physicians employ bioethical principles to justify their position but struggle to reconcile that approach with the broader medical profession's opposition. This study is part of the first tranche of empirical research emerging from Australia since the legalisation of VAD in that country for the first time in over 20 years.

Medical Assistance in Dying: Patients', Families', and Health Care Providers' Perspectives on Access and Care Delivery

Background: Medical assistance in dying (MAID) became legal in Canada in 2016. Although the legislation is federal, each province is responsible for establishing quality care. Objective: To explore patient, family, and health care provider (HCP) perspectives on MAID access and care delivery and improve regional MAID care delivery. Design: Qualitative exploratory. Setting/Subjects: We interviewed 5 patients (4 met the legislated MAID criteria and 1 did not), 11 family members (4 spouses, 5 children, 1 sibling, and 1 friend), and 14 HCP (3 physicians, 4 social workers, and 7 nurses) from June to August 2017. Measurement: Semistructured interviews, content analysis, and thematic summary. Results: Patients, families, and HCPs highlighted access and delivery concerns regarding program sustainability, care pathway ambiguity, lack of support for care choices, institutional conscientious objection (CO), navigating care in institutions with a CO, and postdeath documentation. Patients and families expressed additional concerns regarding lack of ability to provide advanced MAID consent, and the requirement of independent witnesses on MAID request forms and consent immediately before MAID administration. HCPs were additionally uncertain about professional roles and responsibilities. Ten recommendations to improve regional MAID care and the resultant practice change are presented. Conclusion: Quality improvement (QI) processes are essential to devise an accessible dignified patient- and family-centered MAID program. Ensuring patient and family perspectives are integrated into QI initiatives will assist programs in ensuring the needs of all are considered in structuring and staffing a program that is accessible, easy to navigate, and provides dignified end-of-life care in supportive and respectful work environments.

'This is uncharted water for all of us': challenges anticipated by hospital clinicians when voluntary assisted dying becomes legal in Victoria

ObjectiveThe aim of this study was to identify the challenges anticipated by clinical staff in two Melbourne health services in relation to the legalisation of voluntary assisted dying in Victoria, Australia. MethodsA qualitative approach was used to investigate perceived challenges for clinicians. Data were collected after the law had passed but before the start date for voluntary assisted dying in Victoria. This work is part of a larger mixed-methods anonymous online survey about Victorian clinicians’ views on voluntary assisted dying. Five open-ended questions were included in order to gather text data from a large number of clinicians in diverse roles. Participants included medical, nursing and allied health staff from two services, one a metropolitan tertiary referral health service (Service 1) and the other a major metropolitan health service (Service 2). The data were analysed thematically using qualitative description. ResultsIn all, 1086 staff provided responses to one or more qualitative questions: 774 from Service 1 and 312 from Service 2. Clinicians anticipated a range of challenges, which included burdens for staff, such as emotional toll, workload and increased conflict with colleagues, patients and families. Challenges regarding organisational culture, the logistics of delivering voluntary assisted dying under the specific Victorian law and how voluntary assisted dying would fit within the hospital’s overall work were also raised. ConclusionsThe legalisation of voluntary assisted dying is anticipated to create a range of challenges for all types of clinicians in the hospital setting. Clinicians identified challenges both at the individual and system levels. What is known about the topic?Voluntary assisted dying became legal in Victoria on 19 June 2019 under the Voluntary Assisted Dying Act 2017. However there has been little Victorian data to inform implementation. What does this paper add?Victorian hospital clinicians anticipate challenges at the individual and system levels, and across all clinical disciplines. These challenges include increased conflict, emotional burden and workload. Clinicians report concerns about organisational culture, the logistics of delivering voluntary assisted dying under the specific Victorian law and effects on hospitals’ overall work. What are the implications for practitioners?Careful attention to the breadth of staff affected, alongside appropriate resourcing, will be needed to support clinicians in the context of this legislative change.

Clinicians' Perspectives on the Duty to Inform Patients About Medical Aid-in-Dying

Background: As of 2019, ten jurisdictions in the United States have authorized physicians to prescribe a lethal dose of medication to a terminally ill patient for the purpose of hastening death. Relatively little bioethics scholarship has addressed the question of whether physicians have an obligation to inform qualifying patients about aid-in-dying (AID) in permissive jurisdictions and little is known about providers' actual communication practices with respect to this issue. Methods: One hundred and forty-four in-depth, semi-structured interviews were conducted and analyzed using an inductive analytic approach as part of the Vermont Study on Aid-in-Dying. Results: Seventeen respondents, 14 physicians and 3 nurse practitioners, met the inclusion criteria for this sub-study. Eleven respondents indicated that they at least sometimes inform patients about AID. Respondents described multiple factors that influence whether or not they might initiate discussions of AID, including the importance of informing patients of their options for end-of-life care, worries about undue influence, and worries about the potential effects on the patient-provider relationship. For those providers who do initiate discussion of AID at least some of the time, attention to the particulars of each individual patient's situation and the context of the discussion appear to play a role in shaping communication about AID. Conclusions: While initiating a clinical discussion of AID is undoubtedly challenging, our study provides compelling descriptive evidence that some medical providers who support AID do not unilaterally follow the conventional bioethics wisdom holding that they ought to wait for patients to introduce the topic of AID. Future research should investigate how to approach these discussions so as to minimize ethical worries about undue influence or potential negative consequences.

Hospital and Health System Policies Concerning the California End of Life Option Act

Background: The End of Life Option Act (EOLOA) legalized physician aid in dying for competent, terminally ill Californians in 2016. The law allows clinicians, hospitals, and health systems to decide whether to participate. About 4 in 10 California hospitals permit the EOLOA, but little is known about their approaches and concerns. Objective: Describe hospital EOLOA policies and challenges. Design and Measurements: Survey study of hospitals in California, administered September 2017 to March 2018. We describe hospital policies concerning the EOLOA and perform thematic analysis of open-ended questions about challenges, including availability of providers, process of implementing EOLOA, experiences of distress by providers and patients, and questions about medications. Results: Of 315 hospitals surveyed, 270 (86%) responded. Every surveyed hospital had established a position on the EOLOA. Among hospitals permitting EOLOA, 38% required safeguards not required in the law, 87% provided for referral to another provider if the patient's physician did not participate, and 65% counseled staff, if needed. Among hospitals not permitting the EOLOA, nearly all allowed providers to follow patients choosing to pursue the EOLOA elsewhere and most permitted a provider to refer to another provider or system. Most hospitals expressed concerns about implementation of the EOLOA and interest in sharing promising practices. Conclusions: This survey of California hospitals demonstrates considerable heterogeneity in implementing the EOLOA. For many Californians, access to the EOLOA depends on where one receives medical care. Implementation would be improved by hospitals and health systems sharing promising practices.

Hospital Responses to the End of Life Option Act: Implementation of Aid in Dying in California

This survey study of statewide California hospitals evaluates the prevalence and institutional characteristics of hospitals and health systems that have either implemented or opted out of the state’s End of Life Option Act.

Health Care Providers' Experiences with Implementing Medical Aid-in-Dying in Vermont: a Qualitative Study

BACKGROUND

The evolving legal landscape for medical aid-in-dying (AID) in the USA raises clinical and public health challenges and concerns regarding how health care providers will accommodate AID while expanding access to high-quality end-of-life care.

OBJECTIVE

To describe Vermont health care providers' experiences practicing under the "Patient Choice and Control at End of Life" Act.

DESIGN

Qualitative semi-structured interviews analyzed using grounded theory.

PARTICIPANTS

The larger study included 144 health care providers, terminally ill patients, caregivers, policy stakeholders, and other Vermont residents working in 10 out of Vermont's 14 counties. This article reports on a subset of 37 providers who had clinical experience with the law.

MAIN MEASURES

Themes from interviews.

KEY RESULTS

Physicians were roughly split between hospital and community-based practices. Most were women (68%) and the largest subgroup specialized in internal or family medicine (53%). Most of the nurses and social workers were women (89%) and most worked for hospice and home health agencies (61%). We identified five domains in which participants engaged with AID: (1) clinical communication and counseling; (2) the Act 39 protocol; (3) prescribing medication; (4) planning for death; and (5) professional education. How providers experienced these five domains of clinical practice depended on their practice setting and the supportive resources available.

CONCLUSION

Health care providers' participation in AID involves clinical tasks outside of responding to patients' requests and writing prescriptions. Research to identify best practices should focus on all domains of clinical practice in order to best prepare providers.

Prevailing Ethical Dilemmas Encountered by Physicians in Terminal Cancer Care Changed After the Enactment of the Natural Death Act: 15 Years' Follow-up Survey

CONTEXT

Advance directive laws have influences on ethical dilemmas encountered by physicians caring for terminal cancer patients.

OBJECTIVES

To identify the prevailing ethical dilemmas among terminal care physicians 15 years after the Natural Death Act was enacted in Taiwan.

METHODS

This study is a cross-sectional survey from April 2014 to February 2015 using the clustering sampling method and a well-structured questionnaire. Targeted participants included physicians at oncology and related wards or palliative care units where terminal cancer care may be provided in Taiwan.

RESULTS

Among the 500 physicians surveyed, 383 responded (response rate 76.6%) and 346 valid questionnaires were included in the final analysis (effective response rate 69.2%). The most frequently identified ethical dilemma was "place of care," followed by "use of antimicrobial agents" and "artificial nutrition and hydration." The dilemma of "truth telling," which ranked first in the 2005-2006 survey, now ranked at the fourth place. Stepwise logistic regression analysis revealed that female gender and knowledge of palliative care were negatively correlated with the extent of dilemmas regarding issues of "life and death."

CONCLUSION

The prevailing ethical dilemmas have changed in Taiwan 15 years after the enactment of the Natural Death Act, supporting that some previous strategies had worked. Our results suggest that education on the core values of palliative care, improvement of community-based hospice care program, and creating treatment guidelines with prognostication may resolve the current dilemmas. This type of survey should be adapted by individual countries to guide policy decisions on end-of-life care.