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van den Besselaar BN, Sewnaik A, Hoesseini A, Dorr MC, Baatenburg de Jong RJ, Offerman MPJ. Causes and Ways of Death in Patients With Head and Neck Cancer. JAMA Otolaryngol Head Neck Surg 2024; 150:303-310. [PMID: 38358760 PMCID: PMC10870226 DOI: 10.1001/jamaoto.2023.4694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Accepted: 12/15/2023] [Indexed: 02/16/2024]
Abstract
Importance There is limited literature on the exact causes and ways of death in patients with head and neck cancer. To provide optimal care, especially in the palliative phase, more information on this is needed. Objective To provide insights into the causes and ways of death among patients with head and neck cancer. Design, Setting, and Participants This retrospective cohort study included a consecutive population of patients who received a diagnosis of primary squamous cell carcinoma of the head and neck between January 2006 and December 2013 who were treated in the Erasmus MC. Patient data were merged with nonpublic microdata from Statistics Netherlands. Follow-up time was specified as the date of diagnosis until death or December 3, 2019, whichever came first. The data were checked and reanalyzed in November 2023. Main outcomes and Measures Causes (eg, head and neck cancer, other cancer) and ways (eg, natural death, suicide) of death. Results A total of 1291 patients (59.2%; 342 women [26.5%]) died during follow-up (median [IQR] follow-up, 2.7 [1.2-5.6] years). The main cause of death was head and neck cancer (557 [43.1%]), followed by the competing cause of other cancers (344 [26.6%]). In total, 240 patients (18.6%) received palliative sedation and 70 patients (5.4%) euthanasia. Compared with patients with head and neck cancer as the underlying cause of death, lower odds ratios (ORs) were observed for receiving palliative sedation (OR, 0.32 vs 0.07; 95% CI, 0.22-0.46 vs 0.03-0.12) and euthanasia (OR, 0.22 vs 0.01; 95% CI, 0.11-0.41 vs 0-0.107) in patients with other causes of death. Patients with a middle and high income had higher ORs for receiving palliative sedation (OR, 1.46 vs 1.86; 95% CI, 1.05-2.04 vs 1.22-2.85) or euthanasia (OR, 2.25 vs 3.37; 95% CI, 1.18-4.3, 1.6-7.12) compared with low-income patients. Retired patients had lower ORs for receiving palliative sedation or euthanasia compared with employed patients (OR, 0.56 vs 0.44; 95% CI, 0.39-0.8 vs 0.24-0.82). Conclusion and Relevance The results of this cohort study suggest that more than half of the patients died of competing causes and palliative sedation and euthanasia were more common in patients with head and neck cancer as the underlying cause of death. Patients with a higher socioeconomic status had higher odds of receiving palliative sedation and euthanasia. These insights may support health care professionals in providing patient-centered care, especially for patients in the palliative phase.
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Affiliation(s)
- Boyd N. van den Besselaar
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Aniel Sewnaik
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Arta Hoesseini
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Maarten C. Dorr
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Robert. J Baatenburg de Jong
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
| | - Marinella P. J. Offerman
- Department of Otorhinolaryngology and Head and Neck Surgery, Erasmus MC Cancer Institute, University Medical Center Rotterdam, the Netherlands
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Knox M, Wagg A. Contemplating the Impacts of Canadian Healthcare Institutions That Refuse to Provide Medical Assistance in Dying: A Framework-Based Discussion of Potential Health Access Implications. Am J Hosp Palliat Care 2023; 40:1154-1162. [PMID: 36802722 PMCID: PMC10571375 DOI: 10.1177/10499091231155854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
INTRODUCTION Following the historic Canadian legislation on medical assistance in dying (MAiD) in 2016, many implementation challenges and ethical quandaries have formed the focus of further scholarly investigation and policy revisions. Of these, conscientious objections held by some healthcare institutions have involved relatively less scrutiny, despite indicating possible hurdles to the universal availability of MAiD services in Canada. METHODS In this paper, we contemplate potential accessibility concerns that pertain specifically to service access, with the hope to trigger further systematic research and policy analysis on this frequently overlooked aspect of MAiD implementation. We organize our discussion using two important health access frameworks: Levesque and colleagues' Conceptual Framework for Access to Health and the Provisional Framework for MAiD System Information Needs (Canadian Institute for Health Information). RESULTS Our discussion is organized along five framework dimensions through which institutional non-participation may generate or exacerbate inequities in MAiD utilization. Considerable overlaps are revealed across framework domains, indicating the complexity of the problem and the need for further investigation. CONCLUSION Conscientious dissensions on the part of healthcare institutions form a likely barrier to ethical, equitable, and patient-oriented MAiD service provision. Comprehensive, systematic evidence is urgently needed to understand the nature and scope of resulting impacts. We urge Canadian healthcare professionals, policymakers, ethicists, and legislators to attend to this crucial issue in future research and in policy discussions.
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Affiliation(s)
- Michelle Knox
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Adrian Wagg
- Department of Medicine, University of Alberta, Edmonton, AB, Canada
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3
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Knox M, Wagg A. Institutional Resistance to Medical Assistance in Dying in Canada: Arguments and Realities Emerging in the Public Domain. Healthcare (Basel) 2023; 11:2305. [PMID: 37628502 PMCID: PMC10454636 DOI: 10.3390/healthcare11162305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 08/27/2023] Open
Abstract
Since the legalization of medical assistance in dying (MAiD) in Canada in 2016, volitional non-participation in MAiD on the part of some healthcare institutions has revealed ethical uncertainties, potential access problems, and policy gaps. The problem has remained much neglected in the literature base, with no comprehensive studies on the subject so far. We analyzed print media articles and grey literature on institutional objections to and non-participation in MAiD. Thematic analyses were performed on all data to better understand the diverse stakeholder arguments and positions that characterize this important public health debate. Our search yielded 89 relevant media articles and 22 legislative, policy, and other relevant documents published since 2016 in the English language. We identified four main themes about institutional refusals to participate in MAiD, articulated as the following questions: (1) Who has the right to conscience? (2) Can MAiD be considered a palliative practice? (3) Are there imbalances across diverse stakeholder rights and burdens? and (4) Where are the gaps being felt in MAiD service implementation? Stakeholder views about institutional conscience with respect to MAiD are varied, complex, and evolving. In the absence of substantial systematic evidence, public domain materials constitute a key resource for understanding the implications for service access and determining the relevance of this contentious issue for future MAiD research and policy.
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Affiliation(s)
- Michelle Knox
- Department of Medicine, University of Alberta, Edmonton, AB T6G 2P4, Canada
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Kious BM. Medical Assistance in Dying in Neurology. Neurol Clin 2023; 41:443-454. [PMID: 37407098 DOI: 10.1016/j.ncl.2023.03.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.
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Affiliation(s)
- Brent M Kious
- Department of Psychiatry, Center for Bioethics and Health Humanities, University of Utah, 501 Chipeta Way, Salt Lake City, UT 84108, USA.
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5
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Mills A, Bright K, Wortzman R, Bean S, Selby D. Medical assistance in dying and the meaning of care: Perspectives of nurses, pharmacists, and social workers. Health (London) 2023; 27:60-77. [PMID: 33685263 PMCID: PMC9743076 DOI: 10.1177/1363459321996774] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. While it has generated significant academic interest, the experiences of healthcare workers other than physicians remain understudied. This paper reports on a qualitative study of interprofessional Healthcare Providers (HCPs) involved in the provision of MAiD in order to: (1) characterize providers' views about the care they offer in general; (2) examine whether or not they consider MAiD a form of care; and (3) explore their reasons for viewing or not viewing MAiD as care. Semi-structured qualitative interviews were conducted with ten nurses, eight social workers, and three pharmacists with firsthand experience delivering MAiD at an academic hospital in Toronto, Canada. The study was approved by the hospital's REB. Written informed consent was obtained prior to participation. Codebook thematic analysis and template analysis generated four themes: (1) care as advocacy, (2) care as easing suffering, (3) care as psychosocial, and (4) care as relational. Every participant viewed MAiD as a form of care and drew on these four themes to authenticate MAiD as care. Participants consider MAiD a form of care for patients, families, other healthcare workers, and even themselves. In alternating and composite fashion, they describe MAiD in terms of autonomy, easing suffering, and a kind death for the dying (and those entrusted with their care)-a complex choreography of social discourses and moral logics that refuse to settle into a simple dichotomy of "choice versus care." Participants depict MAiD in many of the same terms and imagery they use to describe the care they offer in general. In light of ongoing social controversies surrounding MAiD, HCPs utilize a range of logics strategically to repel negative attention and enable their participation in what they see as a caring end for their patients.
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Affiliation(s)
- Anneliese Mills
- Anneliese Mills, Faculty of Medicine, University of Toronto, C/O Debbie Selby, 2075 Bayview Ave., KGE31, Toronto, ON M4N 3M5, Canada.
| | | | - Rachel Wortzman
- University of Toronto, Canada,Sunnybrook Health Sciences Center, Canada,Department of Family and Community Medicine, Canada
| | - Sally Bean
- Sunnybrook Health Sciences Center, Canada,University of Toronto, Canada
| | - Debbie Selby
- University of Toronto, Canada,Sunnybrook Health Sciences Center, Canada,Department of Family and Community Medicine, Canada
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Variath C, Peter E, Cranley L, Godkin D. Experiences of healthcare providers with eligible patients' loss of decision-making capacity while awaiting medical assistance in dying. Palliat Care Soc Pract 2022; 16:26323524221128839. [PMID: 36268274 PMCID: PMC9577066 DOI: 10.1177/26323524221128839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022] Open
Abstract
Background In Canada, under Bill C-14, patients who met all eligibility requirements were prevented from accessing medical assistance in dying (MAiD) following their loss of decision-making capacity while awaiting MAiD. The changes introduced with Bill C-7 continue to limit access to patients who did not enter a waiver of final consent agreement with their healthcare providers. Little is known about the experiences with patients' loss of capacity to consent and subsequent ineligibility for MAiD. Understanding healthcare providers' experiences has important implications for improving end-of-life care for those with capacity-limiting conditions. Purpose To explore Canadian healthcare providers' experiences with end-of-life of eligible patients who became ineligible for MAiD due to their loss of decision-making capacity to consent and the relational influences on their experiences prior to the implementation of Bill C-7 in Canada. Method A critical qualitative methodology and a feminist ethics theoretical lens guided this study. A voice-centred relational approach that allowed an in-depth exploration of how power, relationality and moral agency influenced participants' experiences was used for data analysis. Data consisted of semi-structured interviews with 30 healthcare providers. Findings The analysis resulted in the following four main themes and corresponding subthemes: (1) identifying factors that may result in ineligibility for MAiD due to capacity loss; (2) maintaining eligibility required to access MAiD; (3) preparing for an alternative end-of-life; (4) experiencing patients' capacity loss. Discussion This study highlights that while MAiD is legally available to eligible Canadians, access to MAiD and care for eligible patients who were unable to access MAiD due to their loss of decision-making varied based on the geographical locations and access to willing MAiD and end-of-life care providers. The availability of high-quality palliative care for patients throughout the MAiD process, including following the loss of capacity to consent and subsequent ineligibility, would improve the end-of-life experience for all those involved. The need to establish a systematic approach to prepare and care for patients and their families following the patients' loss of capacity and subsequent ineligibility for MAiD is also identified.
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Affiliation(s)
| | - Elizabeth Peter
- Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto, Toronto, ON, CanadaJoint Centre for Bioethics,
University of Toronto, Toronto, ON, Canada
| | - Lisa Cranley
- Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto, Toronto, ON, Canada
| | - Dianne Godkin
- Trillium Health Partners-Mississauga Hospital,
Mississauga, ON, CanadaLawrence S. Bloomberg Faculty of Nursing, University
of Toronto, Toronto, ON, CanadaJoint Centre for Bioethics, University of
Toronto, Toronto, ON, Canada
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7
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Bérubé A, Tapp D, Dupéré S, Plaisance A, Bravo G, Downar J, Couture V. Do Socioeconomic Factors Influence Knowledge, Attitudes, and Representations of End-of-Life Practices? A Cross-Sectional Study. J Palliat Care 2022:8258597221131658. [PMID: 36237145 DOI: 10.1177/08258597221131658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
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.
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Affiliation(s)
- A Bérubé
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - D Tapp
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - S Dupéré
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
| | - A Plaisance
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Cardiology Department, Quebec Heart and Lung Institute Research Center-Laval University, Quebec City, QC, Canada
| | - G Bravo
- Faculty of Medicine and Health Sciences, Sherbrooke University, Sherbrooke, QC, Canada
| | - J Downar
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - V Couture
- Faculty of Nursing, 4440Laval University, Pavillon Ferdinand-Vandry, local A-3645-D, Quebec City, QC, Canada
- Population Health and Optimal Health Practices Axis, Research Center of the CHU de Québec-Université Laval, Quebec, QC, Canada
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8
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Frey R, Balmer D. The views of Aotearoa/New Zealand adults over 60 years regarding the End of Life Choice Act 2019. JOURNAL OF RELIGION AND HEALTH 2022; 61:1605-1620. [PMID: 34355303 PMCID: PMC8340805 DOI: 10.1007/s10943-021-01359-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/18/2021] [Indexed: 06/13/2023]
Abstract
This study described the views of older New Zealand adults toward assisted dying and specifically the End of Life Choice Act (2019), an Act making assisted dying legal. An anonymous postal and online survey of 636 adults 60 years and older was conducted. The majority of respondents did not support legalization (85.7%), while 8.8% were in favor (5.5% did not specify a view). Weighted binary logistic regression indicated that the odds of support for legalization were lower in those respondents with a religious affiliation (OR = .020, S.E. = 0.60, p = .00), and there were 2.66 times greater odds in those identifying as male (S.E. = 0.34, p = .005). On the other hand, those respondents under 65 years had increased odds of supporting legalization (OR = 1.89, S.E. = .029, p = .045). Results indicate that most participants were concerned about potential abuses and coercive practices if assisted dying became legally available in New Zealand.
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Affiliation(s)
- Rosemary Frey
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand.
| | - Deborah Balmer
- School of Nursing, Faculty of Medical and Health Sciences, University of Auckland, 85 Park Road, Grafton, Auckland, New Zealand
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Driftmier P, Shaw J. Understanding the Policy Landscape Surrounding Medical Assistance in Dying in Canada's Federal Prison System. JOURNAL OF CORRECTIONAL HEALTH CARE 2022; 28:75-79. [PMID: 35143355 DOI: 10.1089/jchc.20.05.0043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Medical assistance in dying (MAiD) has been legal in Canada since 2016, and the implementation of MAiD for people who are incarcerated has raised ethical and procedural concerns. In this article, we review the current Correctional Service Canada guideline on MAiD alongside a joint report by the Office of the Correctional Investigator (OCI) and the Canadian Human Rights Commission (CHRC) on aging and dying in prison. We echo concerns raised by the OCI and the CHRC about the limits of adequate end-of-life care currently provided to those in custody and offer our analysis of the procedural guideline for MAiD in prison, which we argue to be inadequate in support for patient-centered care and equality in access to health care.
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Affiliation(s)
- Peter Driftmier
- Faculty of Social Work, University of Calgary, Calgary, Canada
| | - Jessica Shaw
- Faculty of Social Work, University of Calgary, Calgary, Canada
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Tran M, Honarmand K, Sibbald R, Priestap F, Oczkowski S, Ball IM. Socioeconomic Status and Medical Assistance in Dying: A Regional Descriptive Study. J Palliat Care 2021; 37:359-365. [PMID: 34747239 PMCID: PMC9344489 DOI: 10.1177/08258597211053088] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: Concerns that medical assistance in dying (MAiD) may harm vulnerable groups unable to access medical treatments and social supports have arisen since the legalization of MAiD on June 17, 2016; however, there is little research on the topic. The purpose of this study is to investigate the socioeconomic status (SES) of patients who request MAiD at the London Health Sciences Centre (LHSC). Methods: A retrospective analysis of patients from the LHSC MAiD database between June 6, 2016 and December 20, 2019 was conducted. Patients were linked to income data from the 2016 Canadian Census, and their corresponding income quintile was a proxy for SES. Geographic information system (GIS) mapping software was used to visualize the distribution of income and MAiD requests. Results: 39.4% of the LHSC catchment area was classified as low SES. Two hundred thirty-seven (58.1%) MAiD requests came from low SES patients and 171 (41.9%) requests came from high SES patients. Two hundred fifty-nine (63.5%) patients who requested a MAiD assessment did not receive MAiD following their request. Of the 237 lower SES patients, 150 (63.3% [95% CI 57.2-69.3]) did not receive MAiD. Of the 171 higher SES patients, 109 (63.7% [95% CI 56.5-70.9]) did not receive MAiD. Conclusion: A disproportionate number of requests for a MAiD assessment at LHSC came from lower SES patients; however, similar proportions of patients who requested MAiD from each SES group received aid in dying. Future research should explore why a disproportionately high number of low SES patients request MAiD at LHSC.
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Affiliation(s)
- Manny Tran
- Western University, London, Ontario, Canada
| | | | | | - Fran Priestap
- London Health Sciences Centre Trauma Program, London, Ontario, Canada
| | | | - Ian M Ball
- Western University, London, Ontario, Canada
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Abstract
The term user involvement is frequently applied in research. Frameworks for patient and informal caregiver participation as coresearchers in studies concerning patients with life-threatening illness are however sparse. The PhD project Dying With Dignity—Dignity-Preserving Care for Older Women Living at Home With Incurable Cancer has implemented a thorough cooperation with patients and informal caregivers from the early stages of the research process. A framework for Patient and Informal Caregiver Participation In Research (PAICPAIR) is suggested—creating a stronger foundation for democracy, equality, and research quality by also promoting active participation among vulnerable people experiencing incurable, life-threatening illness, as coresearchers.
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12
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Redelmeier DA, Ng K, Thiruchelvam D, Shafir E. Association of socioeconomic status with medical assistance in dying: a case-control analysis. BMJ Open 2021; 11:e043547. [PMID: 34035092 PMCID: PMC8154947 DOI: 10.1136/bmjopen-2020-043547] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
OBJECTIVES Economic constraints are a common explanation of why patients with low socioeconomic status tend to experience less access to medical care. We tested whether the decreased care extends to medical assistance in dying in a healthcare system with no direct economic constraints. DESIGN Population-based case-control study of adults who died. SETTING Ontario, Canada, between 1 June 2016 and 1 June 2019. PATIENTS Patients receiving palliative care under universal insurance with no user fees. EXPOSURE Patient's socioeconomic status identified using standardised quintiles. MAIN OUTCOME MEASURE Whether the patient received medical assistance in dying. RESULTS A total of 50 096 palliative care patients died, of whom 920 received medical assistance in dying (cases) and 49 176 did not receive medical assistance in dying (controls). Medical assistance in dying was less frequent for patients with low socioeconomic status (166 of 11 008=1.5%) than for patients with high socioeconomic status (227 of 9277=2.4%). This equalled a 39% decreased odds of receiving medical assistance in dying associated with low socioeconomic status (OR=0.61, 95% CI 0.50 to 0.75, p<0.001). The relative decrease was evident across diverse patient groups and after adjusting for age, sex, home location, malignancy diagnosis, healthcare utilisation and overall frailty. The findings also replicated in a subgroup analysis that matched patients on responsible physician, a sensitivity analysis based on a different socioeconomic measure of low-income status and a confirmation study using a randomised survey design. CONCLUSIONS Patients with low socioeconomic status are less likely to receive medical assistance in dying under universal health insurance. An awareness of this imbalance may help in understanding patient decisions in less extreme clinical settings.
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Affiliation(s)
- Donald A Redelmeier
- Medicine, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
| | - Kelvin Ng
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Deva Thiruchelvam
- Evaluative Clinical Sciences, Sunnybrook Research Institute, Toronto, Ontario, Canada
- Department of Psychology, Institute for Clinical Evaluative Sciences, Toronto, Ontario, Canada
| | - Eldar Shafir
- Public Policy, Princeton University, Princeton, New Jersey, USA
- Psychology, Princeton University, Princeton, New Jersey, USA
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Freeman S, Banner D, Ward V. Hospice care providers experiences of grappling with medical assistance in dying in a hospice setting: a qualitative descriptive study. BMC Palliat Care 2021; 20:55. [PMID: 33845825 PMCID: PMC8042896 DOI: 10.1186/s12904-021-00740-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Accepted: 03/09/2021] [Indexed: 11/20/2022] Open
Abstract
Background Rapid implementation of Medical Assistance in Dying (MAiD) across care settings has challenged providers and organizations, including hospices, to develop and implement new modes of practice. The aim of this study was to examine the effects that legalization of MAiD has had on hospice care provider roles within the non-provider context. Methods Eight in-depth semi-structured interviews were conducted and a qualitative descriptive approach used to examine hospice care providers experiences in a small western Canadian city. In the study context, patients who choose MAiD are cared for until immediately prior to the procedure when they are transferred off-site to undergo MAiD. Inductive and thematic analyses were undertaken. Results Participants experienced practical, philosophical, and professional challenges. Despite the overwhelming desire to support patient autonomy and decision-making, some interpreted patient choice for MAiD as rejection of the natural death experience at the hospice. Patient choice for MAiD initiated a new and different pathway of end-of-life care. While participants felt uncertain how best to support patients undergoing MAiD, they shared mixed optimism on how their care provider roles were evolving as their level of experience broadened. While implementation of MAiD was rapid, the introduction of practical and professional supports has remained slow to materialize, leaving many providers to navigate their own personal and professional positions and practices. Conclusion Care providers require a multi-faceted range of clinical, legal, and logistical supports at the practice, organizational, and health system levels, to facilitate care delivery to those requesting and undergoing MAiD and to promote coordinated and holistic patient-centered care. The different pathway for those who chose MAiD may lead care providers to struggle with relational challenges and interpersonal unease. Further research may address how to support those undergoing MAiD within the hospice context.
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Affiliation(s)
- Shannon Freeman
- School of Nursing, University of Northern British Columbia, 3333 University Way, Prince George, British Columbia, V2N 4Z9, Canada.
| | - Davina Banner
- School of Nursing, University of Northern British Columbia, 3333 University Way, Prince George, British Columbia, V2N 4Z9, Canada
| | - Valerie Ward
- Northern Medical Program, University of Northern British Columbia, 3333 University Way, Prince George, British Columbia, V2N 4Z9, Canada
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14
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Dickman NE, Chicas R. Nursing is never neutral: Political determinants of health and systemic marginalization. Nurs Inq 2021; 28:e12408. [PMID: 33651915 DOI: 10.1111/nin.12408] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 01/29/2021] [Accepted: 02/07/2021] [Indexed: 12/11/2022]
Abstract
The nursing community in the United States polarized in September 2020 between Dawn Wooten's whistleblowing about forced hysterectomies at an immigration center in Georgia and the American Nurses Association's refusal to endorse a presidential candidate despite the Trump administration's mounting failures to address the public health crisis posed by the COVID-19 pandemic. This reveals a need for more attention to political aspects of health outcome inequities. As advocates for health equity, nurses can join in recent scholarship and activism concerning the political determinants of health. In this paper, we examine recent work on the political determinants of health with an aim to add two things. First, we seek to build further on the notion of "political" determinants of health by distinguishing policy and governance structures from dynamics of politicization through appeal to critical disabilities studies. Second, we seek to apply this further nuanced approach to challenge rhetorical uses of "vulnerable populations," where this phrase serves to misrecognize systemic institutionalized forces that actively exploit and marginalize people and groups. By refocusing attention to political systems organized around and perpetuating inequitable health outcomes, nurses and other health care professionals-as well as those whom they serve-can concentrate their effort and power to act on political determinants of health in bringing about more equitable health outcomes.
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Affiliation(s)
- Nathan Eric Dickman
- Humanities and Fine Arts Division, University of the Ozarks, Clarksville, AR, USA
| | - Roxana Chicas
- Emory University School of Medicine, Atlanta, GA, USA
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Redelmeier DA, Detsky AS. Economic Theory and Medical Assistance in Dying. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:5-8. [PMID: 32372250 DOI: 10.1007/s40258-020-00587-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Affiliation(s)
- Donald A Redelmeier
- Department of Medicine, University of Toronto, Toronto, Canada.
- Evaluative Clinical Sciences Program, Sunnybrook Research Institute, Toronto, Canada.
- Institute for Clinical Evaluative Sciences, Toronto, Canada.
- Division of General Internal Medicine, Sunnybrook Health Sciences Centre, G-151, 2075 Bayview Ave, Toronto, ON, M4N 3M5, Canada.
| | - Allan S Detsky
- Department of Medicine, University of Toronto, Toronto, Canada
- Division of General Internal Medicine, Sinai Health System and University Health Network, Toronto, Canada
- Institute for Health Policy, Management, and Evaluation, Toronto, Canada
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16
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McDougall R, Pratt B. Too much safety? Safeguards and equal access in the context of voluntary assisted dying legislation. BMC Med Ethics 2020; 21:38. [PMID: 32404097 PMCID: PMC7222560 DOI: 10.1186/s12910-020-00483-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 05/05/2020] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In June 2019, the Australian state of Victoria joined the growing number of jurisdictions around the world to have legalised some form of voluntary assisted dying. A discourse of safety was prominent during the implementation of the Victorian legislation. MAIN TEXT In this paper, we analyse the ethical relationship between legislative "safeguards" and equal access. Drawing primarily on Ruger's model of equal access to health care services, we analyse the Victorian approach to voluntary assisted dying in terms of four dimensions: horizontal equity, patient agency, high quality care, and supportive social norms. We argue that some provisions framed as safeguards in the legislation create significant barriers to equal access for eligible patients. CONCLUSIONS While safety is undoubtedly ethically important, we caution against an overemphasis on safeguarding in voluntary assisted dying legislation given the implications for equal access.
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Affiliation(s)
- Rosalind McDougall
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie St, Melbourne, VIC, 3010, Australia.
| | - Bridget Pratt
- Centre for Health Equity, Melbourne School of Population and Global Health, University of Melbourne, Level 4, 207 Bouverie St, Melbourne, VIC, 3010, Australia
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Downar J, Fowler RA, Halko R, Huyer LD, Hill AD, Gibson JL. Early experience with medical assistance in dying in Ontario, Canada: a cohort study. CMAJ 2020; 192:E173-E181. [PMID: 32051130 DOI: 10.1503/cmaj.200016] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Medical assistance in dying (MAiD) was legalized across Canada in June 2016. Some have expressed concern that patient requests for MAiD might be driven by poor access to palliative care and that social and economic vulnerability of patients may influence access to or receipt of MAiD. To examine these concerns, we describe Ontario's early experience with MAiD and compare MAiD decedents with the general population of decedents in Ontario. METHODS We conducted a retrospective cohort study comparing all MAiD-related deaths with all deaths in Ontario, Canada, between June 7, 2016, and Oct. 31, 2018. Clinical and demographic characteristics were collected for all MAiD decedents and compared with those of all Ontario decedents when possible. We used logistic regression analyses to describe the association of demographic and clinical factors with receipt of MAiD. RESULTS A total of 2241 patients (50.2% women) were included in the MAiD cohort, and 186 814 in the general Ontario decedent cohort. Recipients of MAiD reported both physical (99.5%) and psychologic suffering (96.4%) before the procedure. In 74.4% of cases, palliative care providers were involved in the patient's care at the time of the MAiD request. The statutory 10-day reflection period was shortened for 26.6% of people. Compared with all Ontario decedents, MAiD recipients were younger (mean 74.4 v. 77.0 yr, standardized difference 0.18);, more likely to be from a higher income quintile (24.9% v. 15.6%, standardized difference across quintiles 0.31); less likely to reside in an institution (6.3% v. 28.0%, standardized difference 0.6); more likely to be married (48.5% v. 40.6%) and less likely to be widowed (25.7% v. 35.8%, standardized difference 0.34); and more likely to have a cancer diagnosis (64.4% v. 27.6%, standardized difference 0.88 for diagnoses comparisons). INTERPRETATION Recipients of MAiD were younger, had higher income, were substantially less likely to reside in an institution and were more likely to be married than decedents from the general population, suggesting that MAiD is unlikely to be driven by social or economic vulnerability. Given the high prevalence of physical and psychologic suffering, despite involvement of palliative care providers in caring for patients who request MAiD, future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to a MAiD request.
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Affiliation(s)
- James Downar
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Robert A Fowler
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Roxanne Halko
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Larkin Davenport Huyer
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Andrea D Hill
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont
| | - Jennifer L Gibson
- Division of Palliative Care (Downar), Department of Medicine, Faculty of Medicine, University of Ottawa; Department of Critical Care (Downar), The Ottawa Hospital, Ottawa, Ont.; Interdepartmental Division of Critical Care Medicine (Fowler), Faculty of Medicine; Institute of Health Policy, Management and Evaluation (Fowler), Dalla Lana School of Public Health, University of Toronto; Office of the Chief Coroner (Halko), Ministry of the Solicitor General, Government of Ontario, Toronto, Ont.; Department of Public Health Sciences (Davenport Huyer), School of Medicine, Queen's University, Kingston, Ont.; Sunnybrook Research Institute and Department of Critical Care Medicine (Hill), Sunnybrook Hospital; Division of Clinical Public Health, Institute of Health Policy, Management and Evaluation, and Joint Centre for Bioethics (Gibson), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.
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