Comparing the attitudes of four groups of stakeholders from Quebec, Canada, toward extending medical aid in dying to incompetent patients with dementia

Characterizing Canadian Social Workers Willing to Be Involved in Medical Assistance in Dying for Persons Lacking Decisional Capacity

Medical assistance in dying (MAID) is available in Canada for competent persons meeting the legal requirements. Extending access to persons lacking decisional capacity is being considered. Social workers may be called upon to accompany these persons through the MAID process. As part of a larger survey, we asked social workers from Quebec whether they would be willing to be involved should advance requests for MAID be legalized. Of the 367 respondents, 291 replied that they would. Using multivariable logistic regression, we identified characteristics that distinguish them from the other social workers surveyed: importance of religious or spiritual beliefs, being born in Canada, having received assisted-death requests from families, professional experiences with MAID, and dreading the prospect of participating in MAID for persons lacking decisional capacity. These findings underline the need for educational interventions that would increase social workers' confidence in providing high-quality care to clients who opt for MAID.

Perception of roles across the interprofessional team for delivery of medical assistance in dying

In 2016, Canada joined many jurisdictions worldwide in legalizing Medical Assistance in Dying (MAiD). Given the paucity of qualitative research regarding the involvement of interprofessional health care providers (HCPs) in MAiD, the goal of this study was to better understand how HCPs viewed their role(s). Semi-structured interviews were conducted with 3 pharmacists, 10 nurses, and 8 social workers at an academic hospital in Toronto. Thematic analysis generated six broad themes: 1) Practical/Technical Component, 2) Education, 3) Support, 4) "Part of the Job," 5) "All of the Job," and 6) Lack of Published Information. While nurses and social workers espoused many commonalities, nursing roles were more "in the moment," whereas social workers viewed their roles as beginning earlier and extending after provision of MAiD. There was a spectrum of how participants perceived their role: pharmacists minimized the task of dispensing medications as an insignificant experience, nurses viewed involvement as consistent with their other professional duties (specifically non-MAiD deaths), and social workers described MAiD as a unique opportunity to employ the full gamut of their skills. The study highlights the importance of supporting HCPs through education and information at both regulatory and research levels, recognizing the key roles they play in MAiD.

Informal care-givers' attitudes towards medical assistance in dying for persons with dementia

Medical assistance in dying (MAID) is legal in Canada but cannot be accessed through an advance request. Some data suggest that informal care-givers of persons with dementia support the legalisation of advance requests for MAID. Opponents argue that care-givers' support is due to society's failure to address their well-documented burden and unmet needs. To our knowledge, this assumption has never been tested. To fill this knowledge gap, we conducted a survey among 204 Canadian informal care-givers of persons with dementia to (a) elicit their attitudes towards allowing no longer competent adults to access MAID through an advance request, and (b) test the hypothesis that attitudes are in part driven by the level of burden experienced by care-givers and unmet needs for support. Attitudes were elicited with a clinical vignette involving a woman with Alzheimer's disease who requests MAID while still competent, or through an advance request for the time after she would lose decisional capacity. Informal care-givers' support for MAID ranged from 60 per cent in the scenario where the person is still competent and likely has several more years to live, to 87 per cent when she is depicted as no longer competent, in severe distress and close to death. Quality-of-life considerations and the value of self-determination were key arguments in support of legalising advance requests for MAID. Using multivariable logistic regression, we found no evidence that burden and unmet support needs influence attitudes towards advance requests for MAID, after controlling for other determinants. These findings contribute new insights into people's attitudes towards the sensitive issue of whether MAID should be extended to persons with dementia-induced decisional incapacity.

Euthanasia in persons with advanced dementia: a dignity-enhancing care approach

In current Western societies, increasing numbers of people express their desire to choose when to die. Allowing people to choose the moment of their death is an ethical issue that should be embedded in sound clinical and legal frameworks. In the case of persons with dementia, it raises further ethical questions such as: Does the person have the capacity to make the choice? Is the person being coerced? Who should be involved in the decision? Is the person's suffering untreatable? The use of Advance Euthanasia Directives (AED) is suggested as a way to deal with end-of-life wishes of persons with dementia. However, in the Netherlands-the only country in which this practice is legal-the experiences of patients, doctors, and relatives have been far from satisfactory.Our paper analyses this complex ethical challenge from a Dignity-Enhancing Care approach, starting from the Dutch experiences with AED as a case. We first consider the lived experiences of the different stakeholders, seeking out a dialogical-interpretative understanding of care. We aim to promote human dignity as a normative standard for end-of-life care practices. Three concrete proposals are then presented in which this approach can be operationalised in order to deal respectfully with the end-of-life choices of persons with dementia.

Do Socioeconomic Factors Influence Knowledge, Attitudes, and Representations of End-of-Life Practices? A Cross-Sectional Study

OBJECTIVE

Access to palliative and end-of-life (EOL) care might be influenced by knowledge, attitudes, and representations of these practices. Socioeconomic factors might then affect what people know about EOL care practices, and how they perceive them. This study aims to compare knowledge, attitudes, and representations regarding EOL practices including assisted suicide, medical assistance in dying, and continuous palliative sedation of adults, according to socioeconomic variables.

METHODS

A cross-sectional community-based questionnaire study featuring two evolving vignettes and five end-of-life practices was conducted in Quebec, Canada. Three sample subgroups were created according to the participants' perceived financial situation and three according to educational attainment. Descriptive analysis was used to compare levels of knowledge, attitudes, and representations between the subgroups.

RESULTS

Nine hundred sixty-six (966) people completed the questionnaire. Two hundred and seventy participants (28.7%) had a high school diploma or less, and 42 participants (4.4%) were facing financial hardship. The majority of respondents supported all end-of-life options and the loosening of eligibility requirements for medical assistance in dying. Differences between subgroups were minor. While respondents in socioeconomically disadvantaged subgroups had less knowledge about EOL practices, those with lower educational attainment were more likely to be in favor of medical assistance in dying, and less likely to favor continuous palliative sedation.

CONCLUSIONS

People living with situational social and economic vulnerabilities face multiple barriers in accessing health care. While they may have poorer knowledge about EOL practices, they have a positive attitude towards medical assistance in dying and assisted suicide, and a negative attitude towards continuous palliative sedation. This highlights the need for future research and interventions aimed at empowering this population and enhancing their access to EOL care.

Advance Care Planning for Seniors Diagnosed with Dementia: A Scoping Review of the Canadian Literature

Advance care planning (ACP) is commonly recommended for persons living with dementia. Increasing age and uncertain disease trajectory add complexity to this process. A scoping review of the Canadian literature was completed to assess the feasibility and acceptability of ACP for seniors (≥ 65 years of age) diagnosed with dementia and to provide practice, policy, and research recommendations towards ACP as a critical aspect of care. Twenty-nine articles were grouped into five themes: (1) feasibility of patient engagement in ACP; (2) opinions regarding medical assistance in dying (MAiD) for incompetent patients; (3) knowledge translation to support persons living with dementia, professionals, and caregivers; (4) barriers to and facilitators of the delivery of holistic dementia care; and (5) Indigenous health considerations. Additional research should consider socio-demographic and social/cultural factors associated with older persons living with dementia's engagement in ACP. Future policies warrant a multidisciplinary approach when reviewing legalities. Finally, ACP knowledge translation should become a routine aspect of dementia care.

Extending Medical Aid in Dying to Incompetent Patients: A Qualitative Descriptive Study of the Attitudes of People Living with Alzheimer’s Disease in Quebec

Background: In Quebec, medical aid in dying (MAiD) is legal under certain conditions. Access is currently restricted to patients who are able to consent at the time of the act, which excludes most people with dementia at an advanced stage. However, recent legislative and political developments have opened the door to an extension of the legislation that could give them access to MAiD. Our study aimed to explore the attitudes of people with early-stage dementia toward MAiD should it become accessible to them. Methods: We used a qualitative descriptive design consisting of eight face-to-face semi-structured interviews with persons living with early-stage Alzheimer’s disease, followed by a thematic analysis of the contents of the interviews. Results and Interpretations: Analysis revealed three main themes: 1) favourable to MAiD; 2) avoiding advanced dementia; and 3) disposition to request MAiD. Most participants anticipated dementia to be a painful experience. The main reasons for supporting MAiD were to avoid cognitive loss, dependence on others for their basic needs, and suffering for both themselves and their loved ones. Every participant said that they would ask for MAiD at some point should it become available to incompetent patients and most wished that it would be legal to access it through a request written before losing capacity. Conclusion: The reasons for which persons with Alzheimer’s disease want MAiD are related to the particular trajectory of the disease. Any policy to extend MAiD to incompetent patients should take their perspective into account.

L’aide médicale à mourir pour les personnes atteintes d’un trouble neurocognitif majeur : analyse des commentaires de participants à une enquête

Nous avons récemment réalisé une enquête postale panquébécoise pour connaître les attitudes de divers groupes face à l’idée d’étendre l’aide médicale à mourir (AMM) à des personnes en situation d’inaptitude. Nous présentons ici les résultats d’analyses qualitatives des commentaires laissés par les répondants à la fin du questionnaire. Celui-ci avait été posté à quatre groupes cibles : des aînés de 65 ans ou plus (n=621), des proches aidants de personnes atteintes d’un trouble neurocognitif majeur (n=471), des infirmières (n=514) et des médecins (n=653) qui prenaient soin de tels patients au moment de l’enquête. Des 1 050 questionnaires retournés, 420 incluent des commentaires. Ces commentaires ont été codés en rubriques, thèmes et sous-thèmes, et la fréquence des rubriques comparée entre les quatre groupes cibles. Le codage a permis d’identifier 23 thèmes et cinq sous-thèmes que nous avons regroupés en sept rubriques principales : 1) le répondant, 2) l’enquête et son questionnaire, 3) les personnes visées par l’extension, 4) leur proches, 5) le système de santé, 6) le cadre législatif qui balise les soins en fin de vie, et 7) la société en général. Ces rubriques ont été repérées dans les quatre groupes cibles, bien qu’à des fréquences différentes pour cinq d’entre elles. La présente étude met ainsi en lumière une panoplie de facteurs susceptibles d’influencer les attitudes face à l’extension de l’AMM aux personnes inaptes. Elle illustre par ailleurs la valeur ajoutée de soumettre des commentaires à une analyse systématique pour mieux comprendre les résultats d’une enquête postale.

Attitudes toward withholding antibiotics from people with dementia lacking decisional capacity: findings from a survey of Canadian stakeholders

Background

Healthcare professionals and surrogate decision-makers often face the difficult decision of whether to initiate or withhold antibiotics from people with dementia who have developed a life-threatening infection after losing decisional capacity.

Methods

We conducted a vignette-based survey among 1050 Quebec stakeholders (senior citizens, family caregivers, nurses and physicians; response rate 49.4%) to (1) assess their attitudes toward withholding antibiotics from people with dementia lacking decisional capacity; (2) compare attitudes between dementia stages and stakeholder groups; and (3) investigate other correlates of attitudes, including support for continuous deep sedation (CDS) and medical assistance in dying (MAID). The vignettes feature a woman moving along the dementia trajectory, who has refused in writing all life-prolonging interventions and explicitly requested that a doctor end her life when she no longer recognizes her loved ones. Two stages were considered after she had lost capacity: the advanced stage, where she likely has several more years to live, and the terminal stage, where she is close to death.

Results

Support for withholding antibiotics ranged from 75% among seniors and caregivers at the advanced stage, to 98% among physicians at the terminal stage. Using the generalized estimating equation approach, we found stakeholder group, religiosity, and support for CDS and MAID, to be associated with attitudes toward antibiotics.

Conclusions

Findings underscore the importance for healthcare professionals of discussing underlying values and treatment goals with people at an early stage of dementia and their relatives, to help them anticipate future care decisions and better prepare surrogates for their role. Findings also have implications for the scope of MAID laws, in particular in Canada where the extension of MAID to persons lacking decisional capacity is currently being considered.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-021-00689-1.

Advance Requests for Medical Assistance in Dying in Dementia: a Survey Study of Dementia Care Specialists

Background

Current Canadian Medical Assistance in Dying (MAiD) legislation requires individuals to have the mental capacity to consent at the time of the procedure. Advance requests for MAiD (ARs for MAiD) could allow individuals to document conditions where MAiD would be desired in the setting of progressive dementia.

Methods

Greater Vancouver area dementia care clinicians from family practice, geriatric medicine, geriatric psychiatry, and palliative care were approached to participate in an online survey to assess attitudes around the appropriateness of ARs for MAiD. Quantitative analysis of survey questions and qualitative analysis of open-ended response questions were performed.

Results

Of 630 clinicians approached, 80 were included in the data analysis. 64% of respondents supported legislation allowing ARs for MAiD in dementia. 96% of respondents articulated barriers and concerns, including determination of capacity, protecting the interests of the future individual, navigating conflict among stakeholders, and identifying coercion. 78% of respondents agreed with a mandatory capacity assessment to create an AR, and 59% agreed that consensus between clinicians and substitute decision-makers was required to enact an AR.

Conclusion

The majority of Vancouver dementia care clinicians participating in this study support legislation allowing ARs for MAiD in dementia, while also articulating ethical and logistical concerns with its application.

Allied Health Care Providers Participating in Medical Assistance in Dying: Perceptions of Support

This study explored the experience of pharmacists, social workers, and nurses who participated in Medical Assistance in Dying (MAiD) in a tertiary care Canadian hospital. Consenting staff participated in qualitative semistructured interviews, which were then analyzed for thematic content. This article reports on the broad theme of "support" from the perspective of the 3 professions, focusing on the diversity in perceptions of support, how MAiD was discussed within health care teams, feelings of gratuitous or excessive gestures of support, ambivalence over debriefs, and the importance of informal support. While pharmacists and social workers generally felt part of a community that supported MAiD, nurses more often expressed opinions as highly divergent. The key finding across all themes was the central importance of the culture on any unit with respect to MAiD and specifically the role of the unit manager in creating either a positive open space for communication or a more silent or closed space. Nursing noted that in the latter setting many gestures of support were experienced as insincere and counterproductive, as were debriefs. We outline several recommendations for managers based on the study results with the intent of tailoring support for all professionals involved in MAiD.

Assessing Public's Attitudes Towards Euthanasia and Assisted Suicide of Persons With Dementia Based on Their Advance Request: An Experimental Survey of US Public

OBJECTIVE

Advance request euthanasia and/or assisted suicide (AR-EAS) in persons with dementia is highly controversial. Results of typical public opinion surveys may not reflect the ethical and practical issues involved in the practice. We tested the impact of incorporating such issues in the assessment of public attitudes toward legalization of AR-EAS.

DESIGN

Online survey (April 27-30, 2020) of 1,711 adults recruited via CloudResearch PrimePanel, matched to U.S. population in age, sex, race and/or ethnicity, education, household income, and political affiliation. After assessing initial attitudes toward legalization of AR-EAS, respondents viewed one of six randomly assigned scenarios depicting an ethical or practical issue in AR-EAS; acceptability of EAS in each scenario as well as general attitudes toward AR-EAS legalization were then elicited.

RESULTS

Approximately 54.4% initially agreed/strongly agreed with AR-EAS legalization; agreement was associated with lower dementia quality-of-life rating, younger age, not being religious, liberal politics, and $75,000-$99,999 income range. After viewing the scenarios, a minority in each scenario arm found the AR-EAS depicted acceptable (20.7%-39.1%; p<0.0001 for all six arms, in comparison with initial legalization question response). Support (agree/strongly agree) for AR-EAS legalization after reading specific scenarios was generally lower (range 36.5%-49.3%; p≤0.0002); change in support for legalization was associated with initial support for legalization, acceptability of AR-EAS in the scenarios, dementia quality-of-life ratings, and race.

CONCLUSION

Informing the public of the ethical and practical complexities in AR-EAS may have significant effects on their attitudes toward legalization. Future surveys should ensure that the public's views reflect sufficient exposure to these complexities.

Physicians' and Public Attitudes Toward Euthanasia in People with Advanced Dementia

BACKGROUND/OBJECTIVES

To explore the opinion of the Dutch general public and of physicians regarding euthanasia in patients with advanced dementia.

DESIGN

A cross‐sectional survey.

SETTING

The Netherlands.

PARTICIPANTS

Random samples of 1,965 citizens (response = 1,965/2,641 [75%]) and 1,147 physicians (response = 1,147/2,232 [51%]).

MEASUREMENTS

The general public was asked to what extent they agreed with the statement “I think that people with dementia should be eligible for euthanasia, even if they no longer understand what is happening (if they have previously asked for it).” Physicians were asked whether they were of the opinion that performing euthanasia is conceivable in patients with advanced dementia, on the basis of a written advance directive, in the absence of severe comorbidities. Multivariable logistic regression was performed to identify factors associated with the acceptance of euthanasia.

RESULTS

A total of 60% of the general public agreed that people with advanced dementia should be eligible for euthanasia. Factors associated with a positive attitude toward euthanasia were being female, age between 40 and 69 years, and higher educational level. Considering religion important was associated with lower acceptance. The percentage of physicians who considered it acceptable to perform euthanasia in people with advanced dementia was 24% for general practitioners, 23% for clinical specialists, and 8% for nursing home physicians. Having ever performed euthanasia before was positively associated with physicians considering euthanasia conceivable. Being female, having religious beliefs, and being a nursing home physician were negatively associated with regarding performing euthanasia as conceivable.

CONCLUSION

There is a discrepancy between public acceptance of euthanasia in patients with advanced dementia and physicians' conceivability of performing euthanasia in these patients. This discrepancy may cause tensions in daily practice because patients' and families' expectations may not be met. It urges patients, families, and physicians to discuss mutual expectations in these complex situations in a comprehensive and timely manner. J Am Geriatr Soc 68:2319–2328, 2020.

The Seismic Shift in End-of-Life Care: Palliative Care Challenges in the Era of Medical Assistance in Dying

Background: Concerns regarding personal, professional, administrative, and institutional implications of medical assistance in dying (MAiD) are of particular interest to palliative and hospice care providers (PHCPs), who may encounter additional moral distress and professional challenges in providing end-of-life (EOL) care in the new legislative and cultural era. Objective: To explore PHCPs' encountered challenges and resource recommendations for caring for patients considering MAiD. Design: Qualitative thematic analysis of audio-recorded semistructured interviews with PHCPs. Setting/Subjects: Multidisciplinary PHCPs in acute, community, residential, and hospice care in Vancouver, Canada, with experience supporting patients who have made MAiD inquiries or requests. Measurements: Interviews were deidentified, transcribed verbatim, and coded by four researchers using a common coding scheme. Key themes were analyzed. Results: Twenty-six PHCP participants included physicians (n = 7), nurses (n = 12), social workers (n = 5), and spiritual health practitioners (n = 2). Average interview length was 52 minutes (range 35-90). Analysis revealed four broad challenges associated with providing EOL care after MAiD legalization: (1) moral ambiguity and provider distress, (2) family distress, (3) interprofessional team conflict, and (4) impact on palliative care. Participants also recommended three types of resources to support clinicians in delivering quality EOL care to patients contemplating MAiD: (1) education and training, (2) pre- and debriefing for team members, and (3) tailored bereavement support. Conclusions: PHCPs encountered multilevel MAiD-related challenges, but noted improvement in organizational policies and coordination. Resources to enhance training, pre- and debriefing, and tailored bereavement may further support PHCPs in providing high-quality EOL care as they navigate the legislative and cultural shifts.

Euthanasia in the case of dementia: a survey among Flemish GPs

BACKGROUND

In Belgium law prohibits euthanasia at the end stage of dementia when patients are no longer able to formulate their will. The number of applications for euthanasia based on dementia is low, but patients and their relatives are searching for access to euthanasia.

AIM

This study assessed the opinions of GPs facing requests for euthanasia in patients with dementia.

DESIGN & SETTING

A cross-sectional survey was performed in general practice. Flemish GPs were invited by email to participate in the study.

METHOD

GPs were reached through the regional GP association and the online survey was open for 4 weeks. The data were then anonymised, analysed, and interpreted. The outcome of interest addresses opinions of Flemish GPs regarding euthanasia in patients with dementia.

RESULTS

A total of 113/308 doctors participated. It was found that 69% agreed that euthanasia in patients without dementia is more acceptable than in patients with dementia. When patients with dementia had concomitant diseases, 59% stated that euthanasia was more acceptable than when patients were 'healthy'. It was also found that 56% agreed the euthanasia law needs adjustments towards patients with dementia. Legal adjustments were supported more by GPs of a younger generation. Non-religious doctors were twice as likely to be in favour of legal adjustments than their religious colleagues; 51% believed that the ability of patients to repeat their will is essential; while 72% of GPs feared pressure from relatives to follow the declaration of will.

CONCLUSION

The Belgian GP has an open attitude towards euthanasia for patients with dementia. There was a willingness to perform euthanasia as the stage of dementia worsened and in cases of terminal conditions. Debate, education, and experience will influence opinion and the legislation process.