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Winters JP, Jaye C, Pickering NJ, Walker S. Providing medically assisted dying in Canada: a qualitative study of emotional and moral impact. JOURNAL OF MEDICAL ETHICS 2024:jme-2024-110137. [PMID: 39209379 DOI: 10.1136/jme-2024-110137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024]
Abstract
PURPOSE Medical assistance in dying (MAiD) in Canada places the medical provider at the centre of the process. The MAiD provider holds primary responsibility for determining eligibility and becomes acquainted with patients' inner desires and expressions of suffering. This is followed by the MAiD procedure of administering the lethal agent and being present at the death of eligible patients. We report participants' perceptions of the emotional and moral impacts of this role. METHODOLOGY Two years after MAiD was legalised in Canada, 22 early-adopting physician providers were interviewed. Data were examined using both phenomenological analysis and a novel ChatGPT-enhanced analysis of an anonymised subset of interview excerpts. FINDINGS Participants described MAiD as emotionally provocative with both challenges and rewards. Providers expressed a positive moral impact when helping to optimise a patient's autonomy and moral comfort with their role in relieving suffering. Providers experienced tensions around professional duty and balancing self with service to others. Personal choice and patient gratitude enhanced the provider experience, while uncertainty and conflict added difficulty. CONCLUSIONS Participants described MAiD provision as strongly aligned with a patient-centred ethos of practice. This study suggests that, despite challenges, providing MAiD can be a meaningful and satisfying practice for physicians. Understanding the emotional and moral impact and factors that enhance or detract from the providers' experience allows future stakeholders to design and regulate assisted dying in ways congruent with the interests of patients, providers, families and society.
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Affiliation(s)
| | - Chrystal Jaye
- General Practice and Rural Health, University of Otago Dunedin School of Medicine, Dunedin, New Zealand
| | | | - Simon Walker
- Bioethics Centre, University of Otago, Dunedin, New Zealand
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Jeanneret R, Prince S. Nurses and Voluntary Assisted Dying: How the Australian Capital Territory's Law Could Change the Australian Regulatory Landscape. JOURNAL OF BIOETHICAL INQUIRY 2024:10.1007/s11673-024-10370-y. [PMID: 38869817 DOI: 10.1007/s11673-024-10370-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2024] [Accepted: 06/01/2024] [Indexed: 06/14/2024]
Abstract
On June 5, 2024, the Australian Capital Territory passed a law to permit voluntary assisted dying ("VAD"). The Australian Capital Territory became the first Australian jurisdiction to permit nurse practitioners to assess eligibility for VAD. Given evidence of access barriers to VAD in Australia, including difficulty finding a doctor willing to assist, the Australian Capital Territory's approach should prompt consideration of whether the role of nurses in VAD should be expanded in other Australian jurisdictions. Drawing on lessons from Canada, which currently permits nurse practitioners to assess patient eligibility, we argue that the time has come for Australian jurisdictions to expand the role of nurses in VAD systems. This would be an important step in ensuring access to VAD for patients in practice. Attention, however, must also be paid to ensuring adequate remuneration of nurses (and doctors) if this goal of promoting access is to be achieved in practice.
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Affiliation(s)
- R Jeanneret
- Medical School and T. C. Beirne School of Law, University of Queensland, 288 Herston Rd, Herston, QLD, 4006, Australia.
| | - S Prince
- Australian Centre for Health Law Research, Queensland University of Technology, 2 George Street, Brisbane, QLD, 4000, Australia
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Shapiro GK, Hunt K, Braund H, Dalgarno N, Panjwani AA, Stevens S, Mulder J, Sheth MS, Stere A, Green S, Gubitz G, Li M. Development of a Canadian Medical Assistance in Dying Curriculum for Healthcare Providers. JOURNAL OF MEDICAL EDUCATION AND CURRICULAR DEVELOPMENT 2024; 11:23821205241272376. [PMID: 39220358 PMCID: PMC11366087 DOI: 10.1177/23821205241272376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2024] [Accepted: 07/07/2024] [Indexed: 09/04/2024]
Abstract
Objectives Medical Assistance in Dying (MAiD) was legalized in Canada in 2016, necessitating greater education and training in MAiD for physicians and nurse practitioners. To meet this need, the Canadian MAiD Curriculum (CMC) was developed to offer a nationally accredited, comprehensive, bilingual, hybrid (synchronous and asynchronous) educational program to support and enhance the practice of MAiD in Canada. Methods This work describes the process of developing the CMC, including its guiding principles and framework. The CMC was guided by constructivism and adult learning theory, preliminary literature review, 5 key principles based on a needs assessment survey, as well as consultation with diverse partners. Results Seven modules were developed: (1) foundations of MAiD in Canada, (2) clinical conversations that includes MAiD, (3) how to do an MAiD assessment, (4) capacity and vulnerability, (5) providing MAiD, (6) navigating complex cases with confidence, and (7) MAiD and mental disorders. An eighth topic on clinician resilience and reflection was woven into each of the 7 modules. Conclusion This curriculum ensures that consistent information is available to healthcare providers concerning the practice of MAiD in Canada. To ensure sustainability, the CMC will continue to be updated alongside the evolution of MAiD policy and services in Canada.
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Affiliation(s)
- Gilla K. Shapiro
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
- Social & Behavioural Health Sciences Division, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Kate Hunt
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Heather Braund
- Office of Professional Development & Education Scholarship, Queen's University, Kingston, Canada
| | - Nancy Dalgarno
- Office of Professional Development & Education Scholarship, Queen's University, Kingston, Canada
- Providence Care Hospital, Kingston, Canada
| | - Aliza A. Panjwani
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
| | - Sarah Stevens
- Canadian Association of MAiD Assessors and Providers, Victoria, Canada
| | - Jeanne Mulder
- Office of Professional Development & Education Scholarship, Queen's University, Kingston, Canada
| | - Madurika S. Sheth
- Office of Professional Development & Education Scholarship, Queen's University, Kingston, Canada
| | - Alison Stere
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
| | - Stefanie Green
- Canadian Association of MAiD Assessors and Providers, Victoria, Canada
| | - Gord Gubitz
- Division of Neurology, Dalhousie University, Halifax, Canada
| | - Madeline Li
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Canada
- Department of Psychiatry, Temerty Faculty of Medicine, University of Toronto, Toronto, Canada
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Close E, Downie J, White BP. Practitioners' experiences with 2021 amendments to Canada's medical assistance in dying law: a qualitative analysis. Palliat Care Soc Pract 2023; 17:26323524231218282. [PMID: 38148894 PMCID: PMC10750527 DOI: 10.1177/26323524231218282] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Accepted: 11/16/2023] [Indexed: 12/28/2023] Open
Abstract
Background In 2016, Canada joined the growing number of jurisdictions to legalize medical assistance in dying (MAiD), when the Supreme Court of Canada's decision in Carter v Canada took effect and the Canadian Parliament passed Bill C-14. Five years later, Bill C-7 introduced several significant amendments. These included removing the 'reasonably foreseeable natural death' requirement (an aspect that was widely debated) and introducing the final consent waiver. Since Bill C-7 is so new, very little research has investigated its operation in practice. Objectives This study investigates the experiences of MAiD assessors and providers regarding the Bill C-7 amendments. It explores implications for understanding and improving regulatory reform and implementation. Design Qualitative thematic analysis of semi-structured interviews. Methods In all, 32 MAiD assessors and providers (25 physicians and 7 nurse practitioners) from British Columbia (n = 10), Ontario (n = 15) and Nova Scotia (n = 7) were interviewed. Results The analysis resulted in five themes: (1) removing barriers to MAiD access; (2) navigating regulatory and systems recalibration; (3) recognizing workload burdens; (4) determining individual ethical boundaries of practice and (5) grappling with ethical tensions arising from broader health system challenges. Conclusion This is one of the first studies to investigate physicians' and nurse practitioners' experiences of the impact of Bill C-7 after the legislation was passed. Bill C-7 addressed key problems under Bill C-14, including the two witnesses requirement and the 10-day waiting period. However, it also introduced new complexities as practitioners decided how to approach cases involving a non-reasonably foreseeable natural death (and contemplated the advent of MAiD for persons with a mental disorder as a sole underlying condition). This study highlights the importance of involving practitioners in advance of legislative changes. It also emphasizes how the regulation of MAiD involves a range of organizations, which requires strong leadership and coordination from the government.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD 4001, Australia
| | - Jocelyn Downie
- Health Law Institute, Faculty of Law and Medicine, Dalhousie University, Halifax, NS, Canada
| | - Ben P. White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, QLD, Australia
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Yan H, Bytautas J, Isenberg SR, Kaplan A, Hashemi N, Kornberg M, Hendrickson T. Grief and bereavement of family and friends around medical assistance in dying: scoping review. BMJ Support Palliat Care 2023; 13:414-428. [PMID: 36100431 PMCID: PMC10803956 DOI: 10.1136/spcare-2022-003715] [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] [Received: 04/18/2022] [Accepted: 08/12/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES The increase in the number of jurisdictions legalising medical assistance in dying (MAiD) has contributed to a growth in the number of family and friends who may face unique elements of grief and bereavement. The aim of this study was to review the literature of grief and bereavement of family and friends following MAiD, and to summarise findings for the development of community resources and programming. METHODS We performed a scoping review with workshop consultation of stakeholders. Six electronic databases and the grey literature were searched for qualitative, quantitative and review articles. Content-analytical techniques and multidisciplinary discussions led to the development of concepts and a conceptual framework. RESULTS Twenty-eight articles met the inclusion criteria. We identified five concepts that impact the grief and bereavement of family/friends: relationships between family/friends and the patient as well as healthcare providers; aspects of MAiD grief which can include secrecy and/or anticipatory grief; preparations which may include family/friends and should be centralised and harmonised; end of life as an opportunity for ceremony; and the aftereffects during which mental health outcomes are studied. CONCLUSION This multidisciplinary scoping review incorporates stakeholder consultation to find that support is needed to address the complicated and changing emotions of family/friends before, during and after a MAiD death. Furthermore, additional societal normalisation of MAiD is necessary to reduce secrecy and stigma and improve the accessibility of resources for family/friends.
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Affiliation(s)
- Han Yan
- U of T IHPME, Toronto, Ontario, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jessica Bytautas
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | | | - Ari Kaplan
- MAiDHouse, Toronto, Ontario, Canada
- Faculty of Law, Western University, London, ON, Canada
| | - Narges Hashemi
- Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
- Temmy Latner Centre for Palliative Care, Toronto, Ontario, Canada
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Bravo G, Delli Colli N, Dumont I, Bouthillier ME, Rochette M, Trottier L. Social workers' experiences with medical assistance in dying: Survey findings from Quebec, Canada. SOCIAL WORK IN HEALTH CARE 2023; 62:193-205. [PMID: 37183409 DOI: 10.1080/00981389.2023.2210624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
As part of a larger survey, we asked social workers whether they had been involved in medical assistance in dying (MAID) so far. Of the 367 survey participants, 141 reported that they had. These were invited to describe their roles, needs, and sense of competence, focusing on their last MAID experience. Roles were diversified, beginning before and extending beyond the provision of MAID. Nearly 60% needed training on MAID. Perceived competence was lower among those lacking training. Findings point to educational needs that must be addressed to ensure the quality of end-of-life care and the well-being of social workers who engage in MAID.
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Affiliation(s)
- Gina Bravo
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Nathalie Delli Colli
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
- School of Social Work, Université de Sherbrooke, Sherbrooke, Canada
| | - Isabelle Dumont
- School of Social Work, Université du Québec à Montréal, Montréal, Canada
| | - Marie-Eve Bouthillier
- Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Marianne Rochette
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Lise Trottier
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
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Coers DO, de Boer ME, Sizoo EM, Smalbrugge M, Leget CJW, Hertogh CMPM. Dealing with requests for euthanasia in incompetent patients with dementia. Qualitative research revealing underexposed aspects of the societal debate. Age Ageing 2023; 52:afac310. [PMID: 36626318 PMCID: PMC9831268 DOI: 10.1093/ageing/afac310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 10/24/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVES In the Netherlands, a case of euthanasia of an incompetent patient with dementia and an advance euthanasia directive (AED) caused great societal unrest and led to a petition signed by more than 450 physicians. In this paper, we investigate these physicians' reasons and underlying motives for supporting the 'no sneaky euthanasia' petition, with the aim of gaining insight into the dilemmas experienced and to map out topics in need of further guidance. METHODS Twelve in-depth interviews were conducted with physicians recruited via the webpage 'no sneaky euthanasia'. General topics discussed were: reasons for signing the petition, the possibilities of euthanasia in incompetent patients and views on good end-of-life care. Data were interpreted using thematic content analysis and the framework method. RESULTS Reasons for supporting the petition are dilemmas concerning 'sneaky euthanasia', the over-simplified societal debate, physicians' personal moral boundaries and the growing pressure on physicians. Analysis revealed three underlying motives: aspects of handling a euthanasia request based on an AED, good end-of-life care and the doctor as a human being. CONCLUSIONS Although one of the main reasons for participants to support the petition was the opposition to 'sneaky euthanasia', our results show a broader scope of reasons. This includes their experience of growing pressure to comply with AEDs, forcing them to cross personal boundaries. The underlying motives are related to moral dilemmas around patient autonomy emerging in cases of decision-making disabilities in advanced dementia. To avoid uncertainty regarding patients' wishes, physicians express their need for reciprocal communication.
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Affiliation(s)
- Djura O Coers
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department Medicine for Older People, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, The Netherlands
| | - Marike E de Boer
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department Medicine for Older People, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, The Netherlands
| | - Eefje M Sizoo
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department Medicine for Older People, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, The Netherlands
| | - Martin Smalbrugge
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department Medicine for Older People, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, The Netherlands
| | - Carlo J W Leget
- University of Humanistic Studies, Care Ethics, Utrecht, The Netherlands
| | - Cees M P M Hertogh
- Amsterdam UMC, location Vrije Universiteit Amsterdam, Department Medicine for Older People, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Aging & Later Life, Amsterdam, The Netherlands
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Thomas R, Pesut B, Puurveen G, Thorne S, Tishelman C, Leimbigler B. Medical Assistance in Dying: A Review of Canadian Health Authority Policy Documents. Glob Qual Nurs Res 2023; 10:23333936231167309. [PMID: 37168395 PMCID: PMC10164855 DOI: 10.1177/23333936231167309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023] Open
Abstract
The purpose of this study was to describe policies developed by English-speaking Canadian health authorities to guide multi-disciplinary healthcare practice in the context of MAID. Seventeen policies from 9 provinces and 3 territories were identified and analyzed thematically. Themes developed from these documents related to ensuring a team approach to care, supporting informed patient choice, creating region-specific guidance on eligibility criteria and safeguards, accommodating conscientious objection, and making explicit organizational responsibilities. Ethical language concerned vulnerability, non-judgmental care, dignity, non-abandonment, confidentiality, moral conscience, and diverse cultural values. Overall, these policies addressed important risk mitigation strategies, acknowledged important social contracts, and supported ethical practice. Collectively, these policies outline important considerations in the evolving Canadian context for other jurisdictions seeking to create policy around assisted death.
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Affiliation(s)
- Robyn Thomas
- University of British Columbia Okanagan, Kelowna, Canada
| | - Barbara Pesut
- University of British Columbia Okanagan, Kelowna, Canada
| | | | - Sally Thorne
- University of British Columbia, Vancouver, 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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Access Isn't Enough: Evaluating the Quality of a Hospital Medical Assistance in Dying Program. HEC Forum 2022; 34:429-455. [PMID: 36018528 DOI: 10.1007/s10730-022-09486-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Revised: 06/18/2022] [Accepted: 06/20/2022] [Indexed: 10/15/2022]
Abstract
Following an initial study of the needs of healthcare providers (HCP) regarding the introduction of Medical Assistance in Dying (MAiD), and the subsequent development of an assisted dying program, this study sought to determine the efficacy and impact of MAiD services following the first two years of implementation. The first of three aims of this research was to understand if the needs, concerns and hopes of stakeholders related to patient requests for MAiD were addressed appropriately. Assessing how HCPs and families perceived the quality of MAiD services, and determining if the program successfully accommodated the diverse needs and perspectives of HCPs, rounded out this quality evaluation. This research implemented a mixed-methods design incorporative of an online survey with Likert scale and open-ended questions, as well as focus groups and interviews with staff and physicians, and interviews with MAiD-involved family members. There were 356 online surveys, as well as 39 participants in six focus groups with HCP, as well as fourteen interviews with MAiD-involved family members. Participants indicated that high-quality MAiD care could only be provided with enabling resources such as policies and guidelines to ensure safe, evidence-based, standardized care, as well as a specialized, trained MAiD team. Both focus group and survey data from HCPs suggest the infrastructure developed by the hospital was effective in delivering high-quality MAiD care that supports the diverse needs of various stakeholders. This study may serve as a model for evaluating the impact and quality of services when novel and ethically-contentious clinical practices are introduced to healthcare organizations.
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Vissers S, Dierickx S, Chambaere K, Deliens L, Mortier F, Cohen J. Assisted dying request assessments by trained consultants: changes in practice and quality - Repeated cross-sectional surveys (2008-2019). BMJ Support Palliat Care 2022:bmjspcare-2021-003502. [PMID: 35768204 DOI: 10.1136/spcare-2021-003502] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Accepted: 06/13/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVES To study changes in the peer consultation practice of assessing assisted dying requests and its quality among trained 'Life End Information Forum' (LEIF) consultants in Belgium between 2008 and 2019. METHODS Cross-sectional surveys conducted in 2008 (N=132) and 2019 (N=527) among all registered LEIF consultants. RESULTS The response rate was 75% in 2008 and 57% in 2019. In 2019 compared with 2008, more LEIF consultants were significantly less than 40 years old (25%/10%, p=0.006) and at least 60 years old (34%/20%, p=0.006). In their activities regarding assessments of assisted dying requests over 12 months, we found a significant increase in the number of patients who did not meet the substantive requirements for assisted dying in 2019 compared with 2008 (1-4 patients: 41.1 %/58.8%, p=0.020). In their most recent assessments of an assisted dying request, LEIF consultants in 2019 made significantly more assessments of patients aged 80 years or older than in 2008 (31%/9%, p<0.001), and significantly fewer assessments for patients with cancer (53%/70%, p=0.034). Regarding adherence to quality criteria for consultation, LEIF consultants discussed unbearable suffering (87%/65%, p=0.003) and alternative treatments (palliative: 48 %/13%, p<0.001; curative: 28%/5%, p=0.002) significantly more often with the attending physician. CONCLUSIONS Changes in peer consultation practice and its quality among LEIF consultants likely reflect changes in assisted dying practice in general, as well as changes in LEIF consultations on more complex cases for which LEIF consultants' expertise is required.
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Affiliation(s)
- Stijn Vissers
- End-of-Life Care Research Group (Vrije Universiteit Brussel & Ghent University), Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Sigrid Dierickx
- End-of-Life Care Research Group (Vrije Universiteit Brussel & Ghent University), Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Kenneth Chambaere
- End-of-Life Care Research Group (Vrije Universiteit Brussel & Ghent University), Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Luc Deliens
- End-of-Life Care Research Group (Vrije Universiteit Brussel & Ghent University), Vrije Universiteit Brussel, Brussels, Belgium
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Freddy Mortier
- End-of-Life Care Research Group (Vrije Universiteit Brussel & Ghent University), Vrije Universiteit Brussel, Brussels, Belgium
- Bioethics Institute Ghent, Ghent University, Ghent, Belgium
| | - Joachim Cohen
- End-of-Life Care Research Group (Vrije Universiteit Brussel & Ghent University), Vrije Universiteit Brussel, Brussels, Belgium
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Hewitt J, Grealish L, Bonner A. Voluntary assisted dying in Australia and New Zealand: Exploring the potential for nurse practitioners to assess eligibility. Collegian 2022. [DOI: 10.1016/j.colegn.2022.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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13
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How can we improve the experiences of patients and families who request medical assistance in dying? A multi-centre qualitative study. BMC Palliat Care 2021; 20:185. [PMID: 34876104 PMCID: PMC8653618 DOI: 10.1186/s12904-021-00882-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 11/16/2021] [Indexed: 01/21/2023] Open
Abstract
Background Medical assistance in dying has been available in Canada for 5 years, but it is unclear which practices contribute to high-quality care. We aimed to describe patient and family perspectives of quality of care for medical assistance in dying. Methods We conducted a multi-centre, qualitative descriptive study, including face to face or virtual one-hour interviews using a semi-structured guide. We interviewed 21 english-speaking patients found eligible for medical assistance in dying and 17 family members at four sites in Canada, between November 2017 and September 2019. Interviews were de-identified, and analyzed in an iterative process of thematic analysis. Results We identified 18 themes. Sixteen themes were related to a single step in the process of medical assistance in dying (MAID requests, MAID assessments, preparation for dying, death and aftercare). Two themes (coordination and patient-centred care) were theme consistently across multiple steps in the MAID process. From these themes, alongside participant recommendations, we developed clinical practice suggestions which can guide care. Conclusions Patients and families identified process-specific successes and challenges during the process of medical assistance in dying. Most importantly, they identified the need for care coordination and a patient-centred approach as central to high-quality care. More research is required to characterize which aspects of care most influence patient and family satisfaction. Supplementary Information The online version contains supplementary material available at 10.1186/s12904-021-00882-4.
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Shapiro GK, Tong E, Nissim R, Zimmermann C, Allin S, Gibson J, Li M, Rodin G. Exploring key stakeholders' attitudes and opinions on medical assistance in dying and palliative care in Canada: a qualitative study protocol. BMJ Open 2021; 11:e055789. [PMID: 34862301 PMCID: PMC8646969 DOI: 10.1136/bmjopen-2021-055789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Accepted: 11/10/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Canadians have had legal access to medical assistance in dying (MAiD) since 2016. However, despite substantial overlap in populations who request MAiD and who require palliative care (PC) services, policies and recommended practices regarding the optimal relationship between MAiD and PC services are not well developed. Multiple models are possible, including autonomous delivery of these services and formal or informal coordination, collaboration or integration. However, it is not clear which of these approaches are most appropriate, feasible or acceptable in different Canadian health settings in the context of the COVID-19 pandemic and in the post-pandemic period. The aim of this qualitative study is to understand the attitudes and opinions of key stakeholders from the government, health system, patient groups and academia in Canada regarding the optimal relationship between MAiD and PC services. METHODS AND ANALYSIS A qualitative, purposeful sampling approach will elicit stakeholder feedback of 25-30 participants using semistructured interviews. Stakeholders with expertise and engagement in MAiD or PC who hold leadership positions in their respective organisations across Canada will be invited to provide their perspectives on the relationship between MAiD and PC; capacity-building needs; policy development opportunities; and the impact of the COVID-19 pandemic on the relationship between MAiD and PC services. Transcripts will be analysed using content analysis. A framework for integrated health services will be used to assess the impact of integrating services on multiple levels. ETHICS AND DISSEMINATION This study has received ethical approval from the University Health Network Research Ethics Board (No 19-5518; Toronto, Canada). All participants will be required to provide informed electronic consent before a qualitative interview is scheduled, and to provide verbal consent prior to the start of the qualitative interview. Findings from this study could inform healthcare policy, the delivery of MAiD and PC, and enhance the understanding of the multilevel factors relevant for the delivery of these services. Findings will be disseminated in conferences and peer-reviewed publications.
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Affiliation(s)
- Gilla K Shapiro
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), University of Toronto, Toronto, Ontario, Canada
| | - Eryn Tong
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Camilla Zimmermann
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Department of Medicine, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Sara Allin
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jennifer Gibson
- Joint Centre for Bioethics, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Madeline Li
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, Toronto, Ontario, Canada
- Global Institute of Psychosocial, Palliative and End-of-Life Care (GIPPEC), University of Toronto, Toronto, Ontario, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
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Medical practitioners' views and experiences of being involved in assisted dying in Victoria, Australia: A qualitative interview study among participating doctors. Soc Sci Med 2021; 292:114568. [PMID: 34801335 DOI: 10.1016/j.socscimed.2021.114568] [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: 05/27/2021] [Revised: 10/18/2021] [Accepted: 11/13/2021] [Indexed: 11/24/2022]
Abstract
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.
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Navigating medical assistance in dying from Bill C-14 to Bill C-7: a qualitative study. BMC Health Serv Res 2021; 21:1195. [PMID: 34736463 PMCID: PMC8567982 DOI: 10.1186/s12913-021-07222-5] [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: 07/09/2021] [Accepted: 10/26/2021] [Indexed: 01/04/2023] Open
Abstract
Background Even as healthcare providers and systems were settling into the processes required for Medical Assistance in Dying (MAID) under Bill C-14, new legislation was introduced (Bill C-7) that extended assisted death to persons whose natural death is not reasonably foreseeable. The purpose of this paper is to describe the experiences of nurses and nurse practitioners with the implementation and ongoing development of this transition. Methods This qualitative longitudinal descriptive study gathered data through semi-structured telephone interviews with nurses from across Canada; cross sectional data from 2020 to 2021 is reported here. The study received ethical approval and all participants provided written consent. Findings Participants included nurses (n = 34) and nurse practitioners (n = 16) with significant experience with MAID. Participants described how MAID had transitioned from a new, secretive, and anxiety-producing procedure to one that was increasingly visible and normalized, although this normalization did not necessarily mitigate the emotional impact. MAID was becoming more accessible, and participants were learning to trust the process. However, the work was becoming increasingly complex, labour intensive, and often poorly remunerated. Although many participants described a degree of integration between MAID and palliative care services, there remained ongoing tensions around equitable access to both. Participants described an evolving gestalt of determining persons’ eligibility for MAID that required a high degree of clinical judgement. Deeming someone ineligible was intensely stressful for all involved and so participants had learned to be resourceful in avoiding this possibility. The required 10-day waiting period was difficult emotionally, particularly if persons worried about losing capacity to give final consent. The implementation of C-7 was perceived to be particularly challenging due to the nature of the population that would seek MAID and the resultant complexity of trying to address the origins of their suffering within a resource-strapped system. Conclusions Significant social and system calibration must occur to accommodate assisted death as an end-of-life option. The transition to offering MAID for those whose natural death is not reasonably foreseeable will require intensive navigation of a sometimes siloed and inaccessible system. High quality MAID care should be both relational and dialogical and those who provide such care require expert communication skills and knowledge of the healthcare system. Supplementary Information The online version contains supplementary material available at 10.1186/s12913-021-07222-5.
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Close E, Willmott L, White BP. Regulating voluntary assisted dying practice: A policy analysis from Victoria, Australia. Health Policy 2021; 125:1455-1474. [PMID: 34588128 DOI: 10.1016/j.healthpol.2021.09.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 09/03/2021] [Accepted: 09/05/2021] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Qld, 4001, Australia.
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Qld, 4001, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, Brisbane, Qld, 4001, Australia
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Brown J, Goodridge D, Thorpe L, Crizzle A. "What Is Right for Me, Is Not Necessarily Right for You": The Endogenous Factors Influencing Nonparticipation in Medical Assistance in Dying. QUALITATIVE HEALTH RESEARCH 2021; 31:1786-1800. [PMID: 33938306 PMCID: PMC8446887 DOI: 10.1177/10497323211008843] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Abstract
Access to medical assistance in dying (MAID) is influenced by legislation, health care providers (HCPs), the number of patient requests, and the patients' locations. This research explored the factors that influenced HCPs' nonparticipation in formal MAID processes and their needs to support this emerging practice area. Using an interpretive description methodology, we interviewed 17 physicians and 18 nurse practitioners who identified as non-participators in formal MAID processes. Nonparticipation was influenced by their (a) previous personal and professional experiences, (b) comfort with death, (c) conceptualization of duty, (d) preferred end-of-life care approaches, (e) faith or spirituality beliefs, (f) self-accountability, (g) consideration of emotional labor, and (h) future emotional impact. They identified a need for clear care pathways and safe passage. Two separate yet overlapping concepts were identified, conscientious objection to and nonparticipation in MAID, and we discussed options to support the social contract of care between HCPs and patients.
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Affiliation(s)
- Janine Brown
- University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
- University of Regina, Saskatoon,
Saskatchewan, Canada
| | | | - Lilian Thorpe
- University of Saskatchewan,
Saskatoon, Saskatchewan, Canada
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Crumley ET, Kelly S, Young J, Phinney N, McCarthy J, Gubitz G. How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study. BMJ Open 2021; 11:e048698. [PMID: 34312206 PMCID: PMC8314721 DOI: 10.1136/bmjopen-2021-048698] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES The aims of this study are: (1) to create a flowchart process model of how medical assistance in dying (MAID) occurs in Nova Scotia (NS), Canada and (2) to detail how NS healthcare professionals are involved in each stage of MAID. The research questions are: how is the MAID process carried out and which professionals are involved at which points? and which roles and activities do professionals carry out during MAID? DESIGN Qualitative process model flowchart study with semistructured interviews. SETTING Primary and secondary care in NS, Canada. PARTICIPANTS Thirty-two interviewees self-selected to participate (12 physicians, 3 nurse practitioners (NP), 6 nurses, 6 pharmacists and 5 healthcare administrators and advocates). Participants were included if they conduct assessments, provide MAID, fill prescriptions, insert the intravenous lines, organise care and so on. RESULTS The flowchart process model details five stages of how MAID occurs in NS: (1) starting the MAID process, (2) MAID assessments, (3) MAID preparation (hospital in-patient, hospital outpatient, non-hospital), (4) day of MAID and (5) post-MAID (hospital in-patient and outpatient, non-hospital, after leaving setting). Nineteen points where the process could stop or be delayed were identified. MAID differs slightly by location and multiple professionals from different organisations are involved at different points. Some physicians and NP provide MAID for free as they cannot be reimbursed or find it too difficult to be reimbursed. CONCLUSIONS Our study adds knowledge about the MAID activities and roles of NS professionals, which are not documented in the international literature. Clinicians and pharmacists spend significant additional time to participate, raising questions about MAID's sustainability and uncompensated costs. The process model flowchart identifies where MAID can stop or be delayed, signalling where resources, training and relationship-building may need to occur. Knowing where potential delays can occur can help clinicians, administrators and policymakers in other jurisdictions improve MAID.
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Affiliation(s)
- Ellen T Crumley
- Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Scarlett Kelly
- Treasury Board of Canada Secretariat, Ottawa, Ontario, Canada
| | - Joel Young
- Dalhousie Medical School, Halifax, Nova Scotia, Canada
| | - Nicole Phinney
- Medical Assistance in Dying Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - John McCarthy
- Medical Assistance in Dying Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Gordon Gubitz
- Neurology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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