Stances on Assisted Suicide by Health and Social Care Professionals Working With Older Persons in Switzerland

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.

Exploring contemporary forms of aid in dying: An ethnography of euthanasia in Belgium and assisted suicide in Switzerland

Drawing on two case studies from large-scale fieldwork carried out on euthanasia in Belgium and assisted suicide in Switzerland, this article focuses on the processes of normalization that structure aid in dying. Normalization takes place through a set of apparatuses only partially derived from current legislation, which underlie the relationships that develop between those requesting aid in dying, healthcare staff, volunteers, and loved ones. The resulting arrangements are specific to each national context, but the empirical data also point to broadly common traits, highlighting new paradigmatic forms of aid in dying in the contemporary era.

The Relationship of Palliative Care With Assisted Dying Where Assisted Dying is Lawful: A Systematic Scoping Review of the Literature

CONTEXT

A central approach of palliative care has been to provide holistic care for people who are dying, terminally ill, or facing life-limiting illnesses while neither hastening nor postponing death. Assisted dying laws allow eligible individuals to receive medically administered or self-administered medication from a health provider to end their life. The implementation of these laws in a growing number of jurisdictions therefore poses certain challenges for palliative care.

OBJECTIVES

To analyze the research literature about the relationship of assisted dying with palliative care, in countries where it is lawful.

METHODS

A five-stage scoping review process was adapted from the Joanna Briggs Institute. Data sources searched through October 2018 were MEDLINE, CINAHL, PsychINFO, SCOPUS, and ProQuest dissertations and theses, with additional material identified through hand searching. Research studies of any design were included, but editorials or opinion articles were excluded.

RESULTS

After reviewing 5778 references from searches, 105 were subject to full-text review. About 16 studies were included: from Belgium (n = 4), Canada (n = 1), Switzerland (n = 2), and the U.S. (n = 9). We found that the relationship between assisted dying and palliative care practices in these locations took varied and sometimes combined forms: supportive, neutral, coexisting, not mutually exclusive, integrated, synergistic, cooperative, collaborative, opposed, ambivalent, and conflicted.

CONCLUSION

The studies in this review cast only partial light on challenges faced by palliative care when assisted dying is legal. There is pressing need for more research on the involvement of palliative care in the developing practices of assisted dying, across a growing number of jurisdictions.

Survey of Mental Health Care Providers’ Perspectives on the Everyday Ethics of Medical-Aid-in-Dying for People with a Mental Illness

Context: In most jurisdictions where medical-aid-in-dying (MAiD) is available, this option is reserved for individuals suffering from incurable physical conditions. Currently, in Canada, people who have a mental illness are legally excluded from accessing MAiD. Methods: We developed a questionnaire for mental health care providers to better understand their perspectives related to ethical issues in relation to MAiD in the context of severe and persistent suffering caused by mental illness. We used a mixed-methods survey approach, using a concurrent embedded model with both closed and open-ended questions. Findings: 477 healthcare providers from the province of Québec (Canada) completed the questionnaire. One third of the sample (34.4%) were nurses, one quarter psychologists (24.3%) and one quarter psycho-educators (24%). Nearly half of the respondents (48.4%) considered that people with a severe mental illness should be granted the right to opt for MAiD as a way to end their suffering. Respondents were more likely to feel comfortable listening to the person and participating in discussions related to MAiD for a mental illness than offering care or the means for the person to access MAiD. Most (86.2%) reported that they had not received adequate/sufficient training, education or preparation in order to address ethical questions surrounding MAiD. Conclusions: The findings highlight how extending MAiD to people with a mental illness would affect daily practices for mental healthcare providers who work directly with people who may request MAiD. The survey results also reinforce the need for adequate training and professional education in this complex area of care.

Medical Assistance in Dying: A Scoping Review to Inform Nurses' Practice

In June 2016, Bill C-14 or Medical Assistance in Dying legislation became law in Canada. With this law came changes to nurses' (ie, nurse practitioner, registered nurse, registered practical nurse) scopes of practice, roles, and responsibilities. While federal law, regulatory, and organizational policies are developed to inform nurses about the practice of medical assistance in dying, there is little evidence examining how nurses' roles and responsibilities are enacted in practice. Therefore, a scoping review was conducted to synthesize the evidence on nurses' roles and responsibilities in relation to medical assistance in dying and to identify gaps in the literature. A secondary aim was to identify organizational supports for nurses to effectively and ethically engage in medical assistance in dying. Using a recognized and rigorous scoping review methodology, the findings from 24 research studies were synthesized in this article. The analysis highlights the importance of effective health care professional engagement with the individual in the decision-making process and of the need to educate, support, and include nurses in providing medical assistance in dying. Overall, the current research on medical assistance in dying is limited in Canada, and more attention is needed on the role of the nurse.

Grief After Euthanasia and Physician-Assisted Suicide

Background: Several countries have regulated euthanasia and physician-assisted suicide (PAS). Research has looked at the experiences of patients, family, and professionals. However, little is known of the effects on bereaved individuals. Aims: We aimed to assess (a) what is known about the grief and mental health of people bereaved by euthanasia or PAS and (b) the quality of the research. Method: Systematic review according to PRISMA guidelines with searches in Cinahl, Embase, PsycINFO, Pubmed, and Scopus. Results: The searches identified 10 articles (eight studies), and the study quality was fair. People bereaved by euthanasia/PAS generally had similar or lower scores on measures of disordered grief, mental health, and posttraumatic stress compared with those who died naturally. Lack of social support and secrecy may compound their grief. Being involved in the decision-making process and having the feeling of honoring the deceased's will may facilitate their grief. Limitations: Studies used self-reports from non-random self-selected participants, were retrospective, and were conducted in only three countries. Conclusion: There is little evidence of increased risk of adverse grief or mental health outcomes in people bereaved by euthanasia/PAS. As more countries legalize assisted dying, high-quality studies of the factors that may hinder or facilitate the grief process are needed.