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

For, against, and beyond: healthcare professionals' positions on Medical Assistance in Dying in Spain

BACKGROUND

In 2021, Spain became the first Southern European country to grant and provide the right to euthanasia and medically assisted suicide. According to the law, the State has the obligation to ensure its access through the health services, which means that healthcare professionals' participation is crucial. Nevertheless, its implementation has been uneven. Our research focuses on understanding possible ethical conflicts that shape different positions towards the practice of Medical Assistance in Dying, on identifying which core ideas may be underlying them, and on suggesting possible reasons for this disparity. The knowledge acquired contributes to understanding its complexity, shedding light into ambivalent profiles and creating strategies to increase their participation.

METHODS

We conducted an exploratory qualitative research study by means of semi-structured interviews (1 h) with 25 physicians and nurses from primary care (12), hospital care (7), and palliative care (6), 17 women and 8 men, recruited from Madrid, Catalonia, and Andalusia between March and May 2023. Interviews were recorded, transcribed, and coded in Atlas.ti software by means of thematic and interpretative methods to develop a conceptual model.

RESULTS

We identified four approaches to MAiD: Full Support (FS), Conditioned Support (CS), Conditioned Rejection (CR), and Full Rejection (FR). Full Support and Full Rejection fitted the traditional for and against positions on MAiD. Nevertheless, there was a gray area in between represented by conditioned profiles, whose participation cannot be predicted beforehand. The profiles were differentiated considering their different interpretations of four core ideas: end-of-life care, religion, professional duty/deontology, and patient autonomy. These ideas can intersect, which means that participants' positions are multicausal and complex. Divergences between profiles can be explained by different sources of moral authority used in their moral reasoning and their individualistic or relational approach to autonomy.

CONCLUSIONS

There is ultimately no agreement but rather a coexistence of plural moral perspectives regarding MAiD among healthcare professionals. Comprehending which cases are especially difficult to evaluate or which aspects of the law are not easy to interpret will help in developing new strategies, clarifying the legal framework, or guiding moral reasoning and education with the aim of reducing unpredictable non-participations in MAID.

Prevalence and Risk Factors Associated with Chronic Occupational Low Back Pain among Healthcare Professionals Working at Hospitals: Exploratory Survey Study

Objective  This study aimed to describe the methodological process for developing a questionnaire to identify the prevalence and risk factors for chronic occupational low back pain in healthcare professionals working at hospitals. Method  An exploratory crossectional survey study was carried out in Belo Horizonte, MG, Brazil, and its metropolitan region, in two stages. Initially, the authors prepared a questionnaire based on the Roland Morris disability questionnaire and sent it to a committee of low back pain specialists for validation using the Delphi technique. The second stage consisted of sending the final questionnaire to health professionals working in a hospital environment for at least 2 years and presenting chronic low back pain for at least 3 months. Results  Validation occurred in two rounds of questionnaire adjustments by a panel consisting of physical therapists and physician experts in the field (orthopedists with more than 3 years of experience). Both rounds had 13 participants. The questionnaire initially consisted of 27 items, and, after validation, it had 19 items. The study included 65 subjects, with an average age of 40.91 years old and an average time working at a hospital of 40 hours per week. The total sample had 76.9% of physicians, 10.8% of physical therapists, and 12.3% of nurses or nursing technicians. Most (52.3%) subjects reported staying in uncomfortable positions affecting the lower back for 5 to 10 hours per day. Conclusion  We developed and validated, using the Delphi technique, a questionnaire on the prevalence and risk factors associated with chronic occupational low back pain among healthcare professionals working at hospitals. This unprecedented tool can benefit the population studied since the questionnaires currently used to evaluate chronic low back pain are not specific for investigating the occupational cause of this condition.

Educational content and strategies to support nurses from culturally and linguistically diverse backgrounds caring for patients considering voluntary assisted dying: The Australian experience

OBJECTIVES

Drawing on findings from a qualitative study that aimed to explore the knowledge and attitudes of nurses from culturally and linguistically diverse (CALD) backgrounds about voluntary assisted dying (VAD). The study also aimed to identify the strategies that assist nurses in their readiness and preparation for exposure to VAD. This paper reports on the educational content and strategies that could assist nurses from CALD backgrounds to be better prepared when they encounter VAD requests.

BACKGROUND

Around the world, healthcare professionals have roles to play in caring for patients requesting voluntary assisted dying. Nurses, particularly those from diverse geographic and clinical settings, have voiced inadequate knowledge and understanding about voluntary assisted dying.

DESIGN

A qualitative descriptive approach was undertaken.

METHODS

Data collection involved one focus group and 16 in-depth interviews. A total of 21 nurses from CALD backgrounds were recruited from one Australian state. Thematic analysis was conducted to interpret the data.

FINDINGS

Nurses identified their knowledge gaps and specified the need for education and workplace training on VAD, its legal and ethical aspects, clarity on their role, communication techniques and how VAD intersects with their practice. They suggested various teaching strategies that could prepare nurses to work safely and confidently in a clinical environment where voluntary assisted dying is an option for patients.

CONCLUSION

Given the high number of nurses from diverse backgrounds working in the Australian health sector, these nurses need to be fully prepared to care for patients requesting VAD.

Medical aid in dying: The role of the nurse practitioner

ABSTRACT

Medical aid in dying (MAID) is a practice that has been expanding in the United States over the past few decades. As it becomes a viable option for a growing portion of the American population, nurse practitioners (NPs) need to be prepared to engage in conversation with patients about the practice. Although historically only physicians were able to participate in MAID, the role has recently expanded to include additional advanced practice providers, including NPs. Reviewing the history of MAID and examining how current legislation affects clinical practice can support the NP's ability to educate and counsel patients about the option. Identifying specific areas in which MAID providers report needing additional training and support can help providers work toward delivering the highest quality patient care possible. As MAID becomes accessible to greater numbers of people, NPs need to be prepared to talk to patients who are navigating serious, life-limiting illnesses about the possibility of MAID.

Opening the Door: Rethinking "Difficult Conversations" about Living and Dying with Dementia

This essay looks closely at metaphors and other figures of speech that often feature in how Americans talk about dementia, becoming part of cultural narratives: shared stories that convey ideas and values, and also worries and fears. It uses approaches from literary studies to analyze how cultural narratives about dementia may surface in conversations with family members or health care professionals. This essay also draws on research on a notable social effect of legalizing medical aid in dying: patients may find it easier to bring up a range of concerns, regardless of whether they have any interest in hastening their own death. The essay proposes that health care professionals rethink an idea prominent within their own culture: that conversations about the end of a person's life are inherently difficult. This framing may make it hard for people facing dementia to bring up their concerns about what lies ahead. We suggest a different way to think about these conversations, using the metaphor of "opening the door" to represent inviting a patient to bring up issues of deepest concern.

A Survey of Clinicians Who Provide Aid in Dying

INTRODUCTION

Little is known about the identity and moral experience of clinicians who provide the option of aid in dying to terminally ill Americans.

METHODS

In May 2023 we distributed an email survey to clinicians registered for the American Clinician's Academy on Medical Aid in Dying listserv.

RESULTS

Of the 72 clinicians who responded, 90% were of white race, 50% were over 60 years old, and 47% had been in practice for over 20 years. Most clinicians report practicing primary care (39%) or hospice/palliative care (33%); 25% of clinicians had training in palliative medicine. 22% described their practice as a specialized "aid-in-dying practice" and 26% either "rarely" or "never" cared for the terminally ill outside the context of aid in dying. A majority (56%) of clinicians were either affiliated with an independent practice or unaffiliated. Before they began aid-in-dying work, 26% of clinicians reported having felt "somewhat" or "very" morally conflicted; after having written an aid in dying prescription, 96% felt "hardly" or "not at all" conflicted. On average, clinicians felt that aid-in-dying laws balance protection of patients with access; 39% believed that the laws were "somewhat" or "overly" protective.

CONCLUSION

Many responding clinicians report caring for patients considering aid in dying in specialized practices or otherwise in unaffiliated or independent practice. Clinicians report that providing aid in dying (and writing an aid-in-dying prescription) resulted in less reported moral conflict toward aid in dying.

Physicians' Attitudes and Experiences with Medical Aid in Dying in Colorado: a "Hidden Population" Survey

BACKGROUND

Approximately 20% of the US population live in states where MAiD is a legal, though highly contentious, practice. Little generalizable data exists on the experiences of MAiD providers who comprise a small, and intentionally hidden, population.

OBJECTIVE

To examine the nature, extent, and consequences of physicians' participation in MAiD.

DESIGN

An anonymous, multi-wave, mailed survey (RR= 55%).

PARTICIPANTS

An enriched sample (n=583) of Colorado physicians caring for potential MAiD patients.

MAIN MEASURES

Physician willingness, preparedness, and participation in a continuum of MAiD activities. Other outcomes include the effects of providing MAiD and the barriers physicians face related to MAiD.

KEY RESULTS

Overall, 81.1% of respondents were willing to discuss MAiD with a patient, 88.3% to refer for MAiD, 46.3% to be a consultant, and 28.1% to be an attending. Fewer felt prepared to discuss MAiD (54.4%), provide a MAiD referral (62.8%), be a consultant (30.7%), or be an attending (18.0%). More than half of respondents (52.3%) had discussed MAiD with a patient, 27.3% provided a MAiD referral, 12.8% had been a MAiD consultant, and 8.5% had been a MAiD attending. Among MAiD consultants and attendings, 75% reported that their most recent MAiD case was emotionally fulfilling and professionally rewarding, though 75% also reported that it was time consuming and 46.9% reported that it was ethically challenging. Common barriers to physician participation in MAiD include lack of knowledge about MAiD (46.8%), the emotional (45.6%) and time (41.7%) investments, and ethical concerns (41.7%).

CONCLUSIONS

Many physicians in our sample are both willing and prepared to discuss MAiD with patients and to provide MAiD referrals. Fewer are prepared and willing to serve as an attending or consultant and fewer have provided these services. MAID consultants and attendings largely report the experience to be emotionally fulfilling and professionally rewarding, but all respondents reported multiple barriers to participation.

A Systematic Review of Barriers and Facilitators to Implementing Assisted Dying: A Qualitative Evidence Synthesis of Professionals' Perspectives

Assisted dying is a divisive topic and draws both lamenting and approving commentary from political, medical, legal, and philosophical domains. This systematic review and qualitative evidence synthesis aims to identify the factors that healthcare professionals experience when working within assisted dying frameworks. PRISMA guidelines for systematic reviews were followed. Search results yielded 15,426 papers with 39 papers meeting inclusion criteria for this review. Remaining papers were subjected to critical appraisal and a thematic synthesis. Eight themes fell under the domain of 'barrier' and represented different personal and professional factors that hinder professionals from delivering assisted dying healthcare. Five themes came under the domain of 'facilitators' and represent factors that contribute to the smooth implementation and delivery of assisted dying services. Health professionals experience a range of factors that both impede and propel delivery of assisted dying frameworks.

Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis

BACKGROUND

Medical assistance in dying (MAiD) traverses challenging and emotionally overwhelming territories: healthcare providers (HCPs) across jurisdictions experience myriad of affective responses secondary to possible tensions between normative and interwoven values, such as sanctity of life, dignity in death and dying and duty to care.

OBJECTIVE

To determine the emotional impact on HCPs involved in MAiD.

METHODS

Inclusion restricted to English language qualitative research studies from four databases (OVID Medline, EMBASE, CINAHL and Scopus), from beginning until 30 April 2021, and grey literature up to August 2021 were searched. Key author, citation and reference searches were undertaken. We excluded studies without rigorous qualitative research methodology. Included studies were critically appraised using the Joanna Briggs Institute's critical appraisal tool. Analysis was conducted using thematic meta-synthesis. The cumulative evidence was assessed for confidence using the Confidence in the Evidence from Reviews of Qualitative Research approach.

RESULTS

The search identified 4522 papers. Data from 35 studies (393 physicians, 169 nurses, 53 social workers, 22 allied healthcare professionals) employing diverse qualitative research methodologies from five countries were coded and analysed. The thematic meta-synthesis showed three descriptive emotional themes: (1) polarised emotions including moral distress (n=153), (2) reflective emotions with MAiD as a 'sense-making process' (n=251), and (3) professional value-driven emotions (n=352).

DISCUSSION

This research attempts to answer the question, 'what it means at an emotional level', for a MAiD practitioner. Legislation allowing MAiD for terminal illness only influences the emotional impact: MAiD practitioners under this essential criterion experience more polarised emotions, whereas those practising in jurisdictions with greater emphasis on allaying intolerable suffering experience more reflective emotions. MAiD practitioner's professional values and their degree of engagement influence the emotional impact, which may help structure future support networks. English language literature restriction and absence of subgroup analyses limit the generalisability of results.

Physician experiences with medical assistance in dying: Qualitative study in northwestern Ontario

OBJECTIVE

To explore physician experiences with medical assistance in dying (MAID).

DESIGN

An exploratory qualitative research approach using thematic analysis.

SETTING

Six communities in northwestern Ontario.

PARTICIPANTS

Twenty-three physicians who perform, refer patients for, or are otherwise affected by MAID.

METHODS

One semistructured focus group and one-to-one interviews, transcribed and analyzed thematically.

MAIN FINDINGS

The legislation of MAID added a layer of complexity to the work of physicians in northwestern Ontario, as MAID requires physician leadership, knowledge, time, and careful implementation. Four themes were identified from the interviews that unpacked this additional layer of complexity: relationships, motivation, time and resources, and getting others on board.

CONCLUSION

The logistics of health care delivery in northwestern Ontario communities are complex and layered, which contributes to the burden of physicians as they work to provide MAID.

Symptom Burden and Complexity in the Last 12 Months of Life among Cancer Patients Choosing Medical Assistance in Dying (MAID) in Alberta, Canada

Background: In 2019, cancer patients comprised over 65% of all individuals who requested and received Medical Assistance in Dying (MAID) in Canada. This descriptive study sought to understand the self-reported symptom burden and complexity of cancer patients in the 12 months prior to receiving MAID in Alberta. Methods: Between July 2017 and January 2019, 337 cancer patients received MAID in Alberta. Patient characteristics were descriptively analyzed. As such, 193 patients (57.3%) completed at least one routine symptom-reporting questionnaire in their last year of life. Mixed effects models and generalized estimating equations were utilized to examine the trajectories of individual symptoms and overall symptom complexity within the cohort over this time. Results: The results revealed that all nine self-reported symptoms, and the overall symptom complexity of the cohort, increased as patients’ MAID provision date approached, particularly in the last 3 months of life. While less than 20% of patients experienced high symptom complexity 12 months prior to MAID, this increased to 60% in the month of MAID provision. Conclusions: Cancer patients in this cohort experienced increased symptom burden and complexity leading up to their death. These findings could serve as a flag to clinicians to closely monitor advanced cancer patients’ symptoms, and provide appropriate support and interventions as needed.

Winging it: a qualitative study of knowledge-acquisition experiences for early adopting providers of medical assistance in dying

Background:

Medical Assistance in Dying (MAID) was legalized in Canada without a designated period for implementation. Providers did not have access to customary alternatives for training and mentorship during the first 1–3 years after legalization.

Objective:

To report on how doctors prepared for their first provision of MAID in the early period after legalization in Canada.

Design:

Qualitative research design within an interpretive phenomenological theoretical framework. We asked participants to describe their experiences preparing for first MAID provision. Analysis of transcripts elicited themes regarding training and information desired by early adopters for provision of newly legalized MAID.

Participants:

Twenty-one early adopting physician-providers in five Canadian provinces were interviewed.

Results:

Few formal training opportunities were available. Many early-adopting providers learned about the procedure from novel sources using innovative methods. They employed a variety of strategies to meet their needs, including self-training and organizing provider education groups. They acknowledged and reflected on uncertainty and knowledge gained from unexpected experiences and missteps. Key phrases from participants indicated a desire for early training and mentorship.

Limitations:

This study included only the perspective of physicians who were providers of MAID. It does not address the training needs for all health practitioners who receive requests for assisted death nor report the patient/family experience.

Conclusion:

The Canadian experience demonstrates the importance of establishing accessible guidance and training opportunities for providers at the outset of implementation of newly legalized assisted dying.

Medical practitioners' views and experiences of being involved in assisted dying in Victoria, Australia: A qualitative interview study among participating doctors

RATIONALE

On June 19, 2019, Assisted Dying (AD) was legalized in the Australian state of Victoria, joining a small but growing cohort of jurisdictions internationally where AD is permitted. Few studies have examined perspectives of doctors who have participated in AD in jurisdictions where it has become legal, despite their pivotal role in the system.

OBJECTIVE

This study aimed to describe the beliefs, experiences and perspectives of doctors who had provided AD during the first 12 months of its operation in Victoria, Australia.

METHOD

In-depth, semi-structured interviews were conducted between April and July 2020 with 32 Victorian doctors who had been involved in the AD process during the first 12-months since it became legal in Victoria. The assumptions underpinning our methodology were guided by a phenomenological approach and reflexive thematic analysis was used to analyze the data.

RESULTS

Five major themes were identified: a nascent approach to care, practising within clinical and legal uncertainty, confronting practices, personal sacrifices and coping amid new challenges. A thematic schema was developed, illustrating that these themes were expressed as a balance of competing tensions of identity for doctors who provided AD for their patients in practice. A major tension was not just how doctors' perceptions impacted their own wellbeing and satisfaction, but also how these challenged their continued involvement in AD and, therefore, the system's overall ability to function.

CONCLUSION

Our findings show that while doctors discussed AD as an ethical practice, it also involved multiple identities with varying sources of meaning, and these identities were sometimes overlapping depending on context. As other jurisdictions increasingly move to legalize AD, a greater appreciation of the different role-based and group-based challenges involved in AD may improve AD implementation strategies.

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.

Regulating voluntary assisted dying practice: A policy analysis from Victoria, Australia

BACKGROUND

Victoria is the first state in Australia to legalise voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). The Victorian law took effect in 2019 after an 18-month implementation period designed to facilitate policy development and other regulatory infrastructure.

OBJECTIVE

To study publicly available policy documents regarding voluntary assisted dying in Victoria and the issues they seek to regulate.

METHODS

Policies were identified using a combination of search strategies to capture documents aimed at a broad range of stakeholders including health practitioners, patients, and families. The policies were thematically analysed using the Framework Method.

RESULTS

The study identified 60 policies and five themes: 1) conceptions of policy purpose; 2) degree of support for VAD; 3) guidance about process; 4) navigating conscientious objection; and 5) conceptualising voluntary assisted dying and its relationship with other aspects of end-of-life care. Outside of the detailed Victorian Government policies, there was little practical guidance for voluntary assisted dying provision. Instead, the non-governmental policies tended to focus on positioning regarding VAD and entry into the process.

CONCLUSION

The study demonstrates the value of a planned implementation period for jurisdictions contemplating voluntary assisted dying reform and highlights the challenges in policymaking for a practice that is contentious for some.

Clinical discussion of Medical Aid-in-Dying: minimizing harms and ensuring informed choice

OBJECTIVE

The implementation of medical aid-in-dying (MAID) poses new challenges for clinical communication and counseling. Among these, health care providers must consider whether to initiate a discussion of MAID with eligible patients who do not directly ask about it. Norms and policies concerning this issue vary tremendously across jurisdictions where MAID is legally authorized, reflecting divergent assumptions about patients' rights to information about end-of-life options and the purpose and potential harms of clinical disclosure.

METHOD

This discussion forum essay draws on informed consent doctrine to analyze two policies concerning clinical communication about MAID: the legal prohibition against provider-initiated discussions of MAID in Victoria, Australia, and the Canadian Association of MAID Assessors and Providers (CAMAP) position that providers have an ethical and professional responsibility to inform eligible patients about MAID.

CONCLUSIONS

Informed consent requires that clinicians strike a balance between minimizing potential harms to patients caused by initiating discussions of MAID and the imperative to inform and counsel patients about all of their legally available medical options.

PRACTICE IMPLICATIONS

Clinicians should be aware of both the importance of communication as a tool to inform patients and the potential for clinical language to cause harm to or to unduly influence patients.

How We Can Improve the Quality of Care for Patients Requesting Medical Assistance in Dying: A Qualitative Study of Health Care Providers

CONTEXT

Since Canada decriminalized medical assistance in dying (MAID) in 2015, clinicians and organizations have developed policies and protocols to implement assisted dying in clinical practice. Five years on, there is little consensus as to what constitutes high-quality care in MAID.

OBJECTIVES

To describe MAID clinicians' perspectives on quality of care in MAID, including challenges, successes, and clinical practice suggestions.

METHODS

We conducted an exploratory, multicenter, and qualitative study at four Canadian centers. Using a semistructured interview guide, we conducted interviews with 20 health care providers. Interviews were transcribed and deidentified before analysis. Adopting a qualitative descriptive approach, we used a thematic analysis to identify primary and secondary themes in the interviews and practice suggestions to improve quality of care to patients who request MAID.

RESULTS

We identified three major themes. 1) Improving access and patient experience: clinicians described struggles in ensuring equitable access to MAID and supporting MAID patients and their families. 2) Supporting providers and sustainability: clinicians described managing MAID workload, remuneration, educational needs, and the emotional impact of participating in assisted dying. 3) Institutional support: descriptions of MAID communication tools and training, use of standardized care pathways, interprofessional collaboration, and human resource planning. Clinicians also described suggestions for clinical practice to improve quality of care.

CONCLUSION

Canadian health care providers described unique challenges in caring for patients who request MAID, along with practices to improve the quality of care.

Development of Voluntary Assisted Dying Training in Victoria, Australia: A Model for Consideration

BACKGROUND

Voluntary assisted dying was legalized in Victoria, Australia in June 2019, and was the first jurisdiction internationally to legislatively mandate training for doctors conducting eligibility assessments of patients. Mandatory training was designed as a safeguard to ensure compliance within the system, so that only eligible patients would gain access to voluntary assisted dying.

OBJECTIVE

This article outlines the development of training mandated for doctors prior to undertaking eligibility assessments for voluntary assisted dying. The training addressed required legal knowledge, including doctors' roles, duties and legal protections, and also provided instruction on relevant clinical skills.

DESIGN

Training design was based on 2 main principles: to comprehensively impart the legal duties imposed by the legislation; and to be readily accessible for busy doctors. The law was first mapped into a curriculum, and circulated to medical colleges, societies and professional organizations as well as international experts for feedback. The training was converted into an online e-learning format and tested at a focus group of doctors.

RESULTS

The training comprises 9 modules including an assessment module. While the predominant focus of the modules is on law, they also contain some clinical components and links to further resources. Modules also contain videos, case studies and interactive exercises. The assessment consists of 30 questions, selected randomly from a question bank, with a pass mark of 90%.

CONCLUSION

The Victorian legislatively-mandated voluntary assisted dying training provides standardized baseline knowledge to enhance the quality and consistency of decision-making by doctors. While further evaluation of this training is needed, it may provide a model for other jurisdictions considering making voluntary assisted dying lawful.

Pharmacist experiences and perspectives with Oregon's Death with Dignity Act

BACKGROUND

Medical aid-in-dying (AID) is increasingly available in the United States. Despite their substantial role in the medication use process, pharmacists' involvement in medical AID has been overlooked.

OBJECTIVE

To describe pharmacist attitudes toward medical AID and experiences with Oregon's Death with Dignity Act (DWDA).

METHODS

Qualitative analysis of Oregon-licensed pharmacists with professional interactions involving Oregon's DWDA. Data were collected through semistructured focus groups and analyzed with immersion-crystallization methods.

RESULTS

Sixteen Oregon pharmacists participated in this study. The participants were almost evenly divided between males and females, who varied in age, years of pharmacy experience, and the number of DWDA encounters. Of these, 14 pharmacists agreed to participate in the DWDA process while 2 declined. Three themes emerged. First, pharmacists identified logistical challenges that negatively affected their ability to assist patients seeking medical AID. Second, pharmacists described the content and other patient counseling considerations for DWDA prescriptions. Third, pharmacists discussed how values and preferences informed their decisions related to medical AID requests.

CONCLUSION

Pharmacists' involvement in medical AID has been largely focused on medication dispensing and patient counseling, and medical AID prescriptions raise unique challenges. Their decisions to participate were frequently tied to support for patient autonomy, although more research is needed to capture the diversity of attitudes, perspectives, and experiences related to their involvement with medical AID, particularly for those who decline to participate. There is a need to develop educational materials and other resources to assist pharmacists in navigating medical AID requests.

"If I were to do this, how would I experience it?" Developing a theoretical framework for exploring pharmacists' practice in the domain of assisted dying

BACKGROUND

Worldwide, pharmacy practice is changing to include new roles and responsibilities. Laws enabling the implementation of assisted dying are expanding in international jurisdictions. Pharmacy practice in assisted dying is subsequently expanding. However, studies of how pharmacists experience their practice when engaged in assisted dying are absent. To progress research into the lived experiences of pharmacists practicing in assisted dying, the development of an inquiry framework to guide such research is the first step.

OBJECTIVE

The objective was to develop a theoretical framework of inquiry for use in subsequent continuing research which may explore the actual experience of pharmacy practice in assisted dying.

METHODS

Perspectives were gathered from expert and senior pharmacists who were anticipating the imminent implementation of assisted dying practice. Analysis focused on understanding what aspects of practice experience were important to them. Interview-conversations centred on the question: If you had the chance to talk to experienced pharmacist practitioners who have been involved in the practice of assisted dying, what aspects regarding their experiences, would you like to know about? A conventional approach to qualitative content analysis was utilized to analyze the data.

RESULTS

Findings summarized questions posed by pharmacists contemplating the implementation of assisted dying practice. These perspectives formed the foundation of a theoretical inquiry framework constituted by 8 inter-related dimensional range-continuums. Each range-continuum, designed to explore the lived experiences of pharmacists in practice, is defined. Examples of how the inquiry dimensions will be used to inform future exploratory research are offered within the framework.

CONCLUSIONS

The theoretical inquiry framework will be used to develop knowledge for pharmacists contemplating participation (or not) in assisted dying practice. It is timely to progress research that reveals the informed experiences of pharmacists that are actually practicing in this area. The framework may be adapted for researching pharmacists' experience in other practice areas and contexts.

Clinician responses to legal requests for hastened death: a systematic review and meta-synthesis of qualitative research

BACKGROUND

The legalisation of medical assistance in dying in numerous countries over the last 20 years represents a significant shift in practice and scope for many clinicians who have had little-to-no training to prepare them to sensitively respond to patient requests for hastened death.

AIMS

Our objective was to review the existing qualitative literature on the experiences of healthcare providers responding to requests for hastened death with the aim of answering the question: how do clinicians make sense of, and respond to patients' expressed wishes for hastened death?

METHODS

We performed a systematic review and meta-synthesis of primary qualitative research articles that described the experiences and perspectives of healthcare professionals who have responded to requests for hastened death in jurisdictions where MAiD (Medical Assistance in Dying) was legal or depenalised. A staged coding process was used to identify and analyse core themes.

RESULTS

Although the response to requests for hastened death varied case-by-case, clinicians formulated their responses by considering seven distinct domains. These include: policies, professional identity, commitment to patient autonomy, personal values and beliefs, the patient-clinician relationship, the request for hastened death and the clinician's emotional and psychological response.

CONCLUSION

Responding to a request for hastened death can be an overwhelming task for clinicians. An approach that takes into consideration the legal, personal, professional and patient perspectives is required to provide a response that encompasses all the complexities associated with such a monumental request.

Relational influences on experiences with assisted dying: A scoping review

BACKGROUND

Family members and healthcare providers play an integral role in a person's assisted dying journey. Their own needs during the assisted dying journey are often, however, unrecognized and underrepresented in policies and guidelines. Circumstances under which people choose assisted dying, and relational contexts such as the sociopolitical environment, may influence the experiences of family members and healthcare providers.

ETHICAL CONSIDERATIONS

Ethics approval was not required to conduct this review.

AIM

This scoping review aims to identify the relational influences on the experiences of family members and healthcare providers of adults who underwent assisted dying and of those unable to access assisted dying due to the loss of capacity to consent.

METHODS

A literature search was conducted in four databases, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature (CINAHL) and PsycINFO. The search retrieved 12,074 articles, a number narrowed down to 172 articles for full-text screening. Thirty-six articles met the established inclusion criteria. A feminist relational framework guided the data analysis.

RESULTS

Five key themes on the influences of family members' and healthcare providers' experiences throughout the assisted dying process were synthesized from the data. They include (1) relationships as central to beginning the process, (2) social and political influences on decision making, (3) complex roles and responsibilities of family members and healthcare providers, (4) a unique experience of death, and (5) varying experiences following death.

CONCLUSION

The feminist relational lens, used to guide analysis, shed light on the effect of the sociopolitical influences and the relationships among patients, families, and healthcare providers on each other's experiences. Addressing the needs of the family members and healthcare providers is vital to improving the assisted dying process. Including families' and healthcare providers' needs within institutional policies and enhancing collaboration and communication among those involved could improve the overall experience.

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.