International Association for Hospice and Palliative Care Position Statement: Euthanasia and Physician-Assisted Suicide

MAiD in America: A Rapid Review of Medical Assistance in Dying in the United States and Its Implications for Practice for Health Care Professionals

The evolving legal landscape associated with medical assistance in dying (MAiD) may pose significant challenges for hospice and palliative care professionals. In the United States, 10 states and 1 jurisdiction have passed legislation allowing MAiD. National organizations, such as the Hospice and Palliative Nurses Association, have created position statements to serve as guides to care. Given the clinical and ethical challenges associated with MAiD, a rapid review was conducted to provide current evidence for policymakers, health care professionals, and researchers to use when considering care management and policy initiatives. Using a systematic approach, publications related to MAiD between 2019 and 2024 were extracted and synthesized. The review provides definitions of terms that differentiate between MAiD, euthanasia, physician-assisted suicide, medically assisted death of the nonterminal patient, and death with dignity. A total of 23 articles were included in the review and categorized into 4 themes: (1) legal, regulatory, and policy concerns; (2) health care professional experience of MAiD; (3) patient and caregiver experience of and communication about MAiD; and (4) disparate access to MAiD.

Willingness to be present throughout patient death via medical aid in dying in a national sample of interdisciplinary US hospice clinicians: a content analysis of rationales

Background

Although medical aid in dying (MAID) legalization continues to expand across the United States, limited research has elucidated attitudes toward its clinical provision, especially in terms of clinician presence.

Objective

The objective of the current study was to explore attitudes toward presence throughout a patient's death via MAID in hospice physicians, nurses, social workers, and chaplains. Aims included (1) characterizing willingness to be present throughout patient death via MAID and (2) describing rationales for willingness.

Design

We employed a cross-sectional design.

Methods

A national convenience sample of interdisciplinary hospice clinicians in the United States (N = 413) completed a self-administered, mixed-method survey via Qualtrics. A quantitative item assessing participants' willingness (no, unsure, yes) to be present throughout a patient's death via MAID preceded a qualitative probe inquiring about their rationales behind their previous response. Quantitative responses were characterized through frequencies and percentages. Qualitative responses within each resulting quantitative subsample were content analyzed for surface-level meaning using inductive coding.

Results

Participants who were willing to be present (n = 305 [74%]) attributed their willingness to personal support, definitions of quality clinical care, and values from their professional training. Some engaged in boundary setting, describing particular conditions under which they would be willing to be present. Those who were unwilling (n = 63 [15%]) noted personal objections to the concept of MAID, personal objections to MAID participation, and perceptions of MAID's misalignment with healthcare. Those who were unsure (n = 45 [11%]) premised their responses on ambivalence and a lack of experience, both of which precluded formulating a definitive position.

Conclusion

Although three-quarters of participants were willing to be present during MAID, qualitative responses revealed great nuance within and across quantitative subsamples. Hospice clinicians would benefit from greater professional guidance and support pertaining to MAID.

Position statement of the Brazilian Palliative Care Academy on withdrawing and withholding life-sustaining interventions in the context of palliative care

The issue of withrawing and withholding life-sustaining interventions is an important source of controversy among healthcare professionals caring for patients with serious illnesses. Misguided decisions, both in terms of the introduction/maintenance and the withdrawal/withholding of these measures, represent a source of avoidable suffering for patients, their loved ones, and healthcare professionals. This document represents the position statement of the Bioethics Committee of the Brazilian Palliative Care Academy on this issue and establishes seven principles to guide, from a bioethical perspective, the approach to situations related to this topic in the context of palliative care in Brazil. The position statement establishes the equivalence between the withdrawal and withholding of life-sustaining interventions and the inadequacy related to initiating or maintaining such measures in contexts where they are in disagreement with the values and care goals defined together with patients and their families. Additionally, the position statement distinguishes strictly futile treatments from potentially inappropriate treatments and elucidates their critical implications for the appropriateness of the medical decision-making process in this context. Finally, we address the issue of conscientious objection and its limits, determine that the ethical commitment to the relief of suffering should not be influenced by the decision to employ or not employ life-sustaining interventions and warn against the use of language that causes patients/families to believe that only one of the available options related to the use or nonuse of these interventions will enable the relief of suffering.

Medically Assisted Death and the Ends of Medicine

This paper aims to refute a common line of argument that it is immoral for physicians to engage in medical assistance in death (MAiD), i.e., the practices of euthanasia and physician-assisted suicide. The argument in question is based on the notion that participating in MAiD is contrary to the professional-role obligations of physicians, due to MAiD's putative inconsistency with the ends of medicine. The paper describes several major flaws from which that argument suffers.

Psychological Factors Influencing Attitudes towards Euthanasia, Assisted Suicide and Palliative Care among Medical Students and Doctors in Training

Background: This study aimed to analyse the attitudes of medical students, Polish and classical philology students and trainee doctors towards the legalisation and practice of euthanasia and assisted suicide, to explore their beliefs about palliative care and to identify the cognitive, behavioural and emotional factors influencing these attitudes. Methods: An anonymous 22-question survey was sent by email to 670 participants, who comprised students of medicine, students of Polish and classical philology and trainee physicians. Results: Out of the 670 people invited to the survey, 313 (46.72%) responded; 215 (68.69%) and 112 (35.80%) participants supported the legalisation of euthanasia and assisted suicide, respectively. No differences were found between the respondent groups studied. The respondents' attitudes were influenced by religion, place of residence and professed values in the doctor-patient relationship. Among the medical students and trainee doctors surveyed, the declared willingness to perform euthanasia was lower, with 90 (43.7%) people, than the support for its legalisation, with 135 (65.5%) people. Significantly higher support for palliative care was expressed by fifth- and sixth-year medical students and trainee doctors, with 88 respondents (89.89%), less support was expressed by first- and fourth-year medical students, with 74 respondents (68.5%), and the lowest support was observed among Polish and classical philology students, with 63 respondents (58.9%). Conclusions: The legalisation of euthanasia and assisted suicide was supported by more than two-thirds and one-third of all the respondents, respectively, with the majority of medical students and trainee doctors surveyed expressing uncertainty or lack of readiness towards their practice. More than 70% of all the respondents showed a positive opinion towards palliative care, with the lowest support being among Polish and classical philology students.

The paradoxical position of nurses regarding euthanasia and its legalisation: A descriptive quantitative study

AIMS AND OBJECTIVES

To learn about the attitudes of nurses working in the Andalusian Public Health System regarding euthanasia and its legalisation.

BACKGROUND

Euthanasia often finds itself in the crosshairs of ethical and political debate on an international scale. Currently, the Spanish Organic Law 3/2021 of 24 March, 2021, recognises euthanasia as a fundamental right in Spain. It is of particular interest to know about the views, attitudes and stances that Andalusian nurses have of euthanasia as they are key players within the framework of euthanasia and administration of life-ending drugs. They play a central role in guiding patients through the euthanasia application process.

DESIGN

Observational descriptive study.

METHODS

A study of Andalusian Public Health System nurses was carried out using non-probability convenience sampling. 518 nurses with an average age of 44.75 years answered in a questionnaire that was distributed on an online platform. Socio-demographic and occupational variables were assessed, together with the Death Anxiety Scale and the Euthanasia Attitude Scale. A bivariate analysis and a multivariate linear regression model were performed. The STROBE checklist was used.

RESULTS

The mean score obtained on the Euthanasia Attitude Scale was 75.95 (SD = 16.53). The mean score obtained on the Death Anxiety Scale was 7.56 (SD = 3.05). The variables age and work experience were negatively correlated with the total scores of the Euthanasia Attitude Scale and the categories 'Ethical considerations', 'Practical considerations' and 'Treasuring life'. On the other hand, there was a significant positive correlation between age and work experience and 'Spiritual beliefs' category.

CONCLUSIONS

The current situation shows a worrying paradox. There is a stark difference between positive professional attitudes towards euthanasia and the desire to participate in its application.

RELEVANCE TO CLINICAL PRACTICE

It is vital that educational and healthcare institutions make the necessary efforts to ensure that nurses develop sound moral judgement, displaying the moral conscience and ethical commitment required of this established profession.

PATIENT OR PUBLIC CONTRIBUTION

No patient or public contribution.

Objections to assisted dying within institutions: systemic solutions for rapprochement

In this Matters Arising article, we outline how the recent article "The impact on patients of objections by institutions to assisted dying: a qualitative study of family caregivers' perceptions" (White et al., 2023 Mar 13;24(1):22) informed Voluntary Assisted Dying (VAD) implementation in our large Australian public health setting, where objections do not emanate from, but within, the institution. In reporting the harms to patients and caregivers created by institutional objection, White et al. provide an evidenced-based road map for potential potholes or risks associated with VAD implementation. We discuss the complexities emerging from the diverse views of health professionals and the ethical tensions arising from such, especially within certain specialties, and how we developed systemic strategies that support patients, caregivers and staff alike. We highlighted the need to shift from "Do you support VAD?" to "How can we support you as healthcare professionals to integrate VAD into your practice, in a way that complies with the legislation, meets the needs of patients and caregivers, and feels safe and does not compromise your moral stance?"

'How is it possible that at times we can be physicians and at times assistants in suicide?' Attitudes and experiences of palliative care physicians in respect of the current legal situation of suicide assistance in Switzerland

INTRODUCTION

Switzerland lacks specific legal regulation of assistance in suicide. The practice has, however, developed since the 1980s as a consequence of a gap in the Swiss Criminal Code and is performed by private right-to-die organisations. Traditionally, assistance in suicide is considered contrary to the philosophy of palliative care. Nonetheless, Swiss palliative care physicians regularly receive patient requests for suicide assistance. Their attitudes towards the legal regulations of this practice and their experience in this context remain unclear.

OBJECTIVES

Our study aimed to explore and describe the attitudes and experiences of Swiss palliative care physicians concerning the legal situation of suicide assistance.

METHODS

In 2019, we performed an exploratory interview study with 12 Swiss palliative care physicians on palliative sedation as an alternative to assisted suicide. In this paper, we present the results that emerged from a thematic subanalysis of the data.

RESULTS

Participants stated that assistance in suicide and palliative care are based on opposing philosophies, but they admitted a shift in paradigm over the last years in the sense that one practice does not necessarily exclude the other. They reported various roles in suicide assistance and considered that the current activities of Swiss right-to-die organisations were problematic and needed to be regulated by law.

DISCUSSION AND CONCLUSION

These results could enrich national and international reflection on suicide assistance in the context of palliative care by reducing confusion between the two practices and strengthening the confidence of patients and their relatives.

Medical Assistance in Dying in Neurology

An increasing number of jurisdictions have legalized medical assistance in dying (MAID) with significant variation in the procedures and eligibility criteria used. In the United States, MAID is available for persons with terminal illnesses but is frequently sought by persons with neurologic conditions. Persons with conditions that cause cognitive impairment, such as Alzheimer dementia, are often ineligible for MAID, as their illness is not considered terminal in its early stages, whereas in later stages, they may have impaired decision-making capacity.

Exploring caregivers' perceptions of community-based service requirements of patients with spinal cord injury: a qualitative study

BACKGROUND

The incidence of spinal cord injury is increasing worldwide. Patients with spinal cord injury and their families face many difficulties during the disease course. Caregivers are more involved with these patients than anyone else, so recognizing patients' care requirements based on caregivers' opinions can facilitate care provision to these people. The purpose of this study was to explore caregivers' perceptions of the community-based services requirements of patients with spinal cord injury.

METHODS

This qualitative research was conducted in Iran from Apr 2021 to Dec 2022 using the conventional content analysis method. The participants in the study included family caregivers and providers of home care services to patients with spinal cord injury, who were selected by purposeful sampling. Data were collected by conducting 14 face-to-face interviews and analyzed based on the method proposed by Lundman and Graneheim.

RESULTS

Data analysis led to the extraction of 815 primary codes, which were organized into two themes: community reintegration (with two categories, including the need to provide a suitable social platform and lifelong care) and palliative care (with two categories, including family conference and survival management).

CONCLUSION

Social facilities and infrastructure should be modified in a way that patients with spinal cord injury can appropriately benefit from community-based care services and an independent satisfactory life. Palliative care should be continuously provided from the time of lesion development until the patient's death.

“Respecting our patients’ choices”: making the organizational decision to participate in voluntary assisted dying provision: findings from semi-structured interviews with a rural community hospice board of management

Background

There is limited literature around how palliative care organizations determine the degree to which they will interface with voluntary assisted dying in jurisdictions where it is legal. The aim of this research was to describe the experience of the board of management of an Australian community-based hospice during their decision-making process around whether to support voluntary assisted dying in the facility, prior to the legislation coming into operation.

Methods

The Board considered this decision over ten meetings in 2020, during which time they received information on the legislation, relevant literature, feedback from workshops which included the community, comment from hospice founders, staff survey results and presentations by clinicians able to discuss the impact of voluntary assisted dying on palliative care services. Members were encouraged to make notes of their own experiences during this time. Following this, semi-structured interviews were conducted with seven of the nine board members. Interviews were audio-recorded and transcribed verbatim and analysed using conventional qualitative content analysis method.

Results

The board members experienced a sense of journey in reaching an overall decision, which was to allow full participation in voluntary assisted dying provision for inpatients. Themes based on the journey motif included: starting from a personal view; moving to a hospice perspective; exploring if voluntary assisted dying can be part of end-of-life care; awareness and assessment of risks to the Hospice; arriving at a common platform to vote on; factors facilitating a safe decision-making journey; and personal impact of the journey.

Conclusions

The group highlighted several facilitators of a successful outcome including having adequate time, the availability of useful resources, sound board processes and a trusting culture. The study may provide support to other healthcare organisations as they face similar decisions triggered by legislative change.

End-of-life care of people with long-term neurological conditions

Guidance and protocols of end-of-life care have been directed towards the care of patients with cancer. It is possible to extrapolate some of these to people with long-term neurological conditions, but there are obvious differences. Neurological conditions have widely different time courses of progression, making the timing of these discussions challenging. The common issues around end-of-life care include knowing when to start discussions, approaching advance planning, managing common symptoms, diagnosing the dying phase, withdrawing life-sustaining treatments, providing support for family and carers and judging how to involve specialist palliative care teams. End-of-life care needs close collaboration between neurology, specialist palliative care and general practice.

Ambivalence toward euthanasia and physician-assisted suicide has decreased among physicians in Finland

Background

Debates around euthanasia and physician-assisted suicide (PAS) are ongoing around the globe. Public support has been mounting in Western countries, while some decline has been observed in the USA and Eastern Europe. Physicians’ support for euthanasia and PAS has been lower than that of the general public, but a trend toward higher acceptance among physicians has been seen in recent years. The aim of this study was to examine the current attitudes of Finnish physicians toward euthanasia and PAS and whether there have been changes in these attitudes over three decades.

Methods

A questionnaire survey was conducted with all Finnish physicians of working age in 2020 and the results were compared to previous studies conducted in 1993, 2003 and 2013.

Results

The proportions of physicians fully agreeing and fully disagreeing with the legalization of euthanasia increased from 1993 to 2020 (from 5 to 25%, p < 0.001, and from 30 to 34%, p < 0.001, respectively). The number of physicians, who expressed no opinion for or against euthanasia (cannot say) decreased from 19 to 5% (p < 0.001) during the same period. The proportion of physicians having no opinion (cannot say) of whether a physician should be punished for assisting in a suicide decreased from 20 to 10% (p < 0.001).

Conclusions

This study shows that Finnish physicians’ ambivalence toward euthanasia and PAS has decreased. The ongoing debate has probably forced physicians to form more solid opinions on these matters. Our study highlights that attitudes toward euthanasia and PAS are still divided within the medical profession.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12910-022-00810-y.

Opinions of nurses regarding Euthanasia and Medically Assisted Suicide

BACKGROUND

Safeguarding the right to die according to the principles of autonomy and freedom of each person has become more important in the last decade, therefore increasing regulation of Euthanasia and Medically Assisted Suicide (MAS).

AIMS

To learn the opinions that the nurses of the autonomous region of Madrid have regarding Euthanasia and Medically Assisted Suicide.

RESEARCH DESIGN

Cross-sectional descriptive study.

PARTICIPANTS AND RESEARCH CONTEXT

All registered nurses in Madrid. The study was done by means of a self-completed anonymous questionnaire. The variables studied were social-demographic, giving opinions about Euthanasia and MAS.

ETHICAL CONSIDERATIONS

Each participant was assured maximum confidentiality and anonymity, ensuring the ethical principles set out in the Declaration of Helsinki, as well as in the Organic Law 3/2018, on Personal Data Protection and guarantee of digital rights.

FINDINGS

A total of 489 nurses answered the questionnaire. In total, 75.7% of the nurses confirmed that Euthanasia should be regulated in Spain. 66.3% indicated that information on Euthanasia should be provided jointly by doctors and nurses, and 42.3% considered that it could be applied by both medical and nursing professionals. A total of 87.2% advocated the participation of nurses in health policy, influencing the drafting of the law. In the face of possible regulation, 35% would request Conscientious Objection, being closely related to their religious beliefs.

DISCUSSION

Different authors point out that nurses' perceptions and attitudes towards Euthanasia are conditioned by different factors, such as religion, gender, poor palliative care, legality and the patient's right to die.

CONCLUSION

Nurses are positioned in favour of the regulation and practice of Euthanasia and MAS, depending on their age, years of experience, training, model of care and especially religious beliefs.

Validation of the Greek Version of Euthanasia Attitude Scale (EAS) in Greek Medical Doctors

This study aimed to examine the reliability and validity of the Euthanasia Attitude Scale (EAS) in Greek medical doctors. A cross-sectional study design was conducted, including 120 physicians at clinical setting in 2019 (men 64.5%). A self-report questionnaire, including socio-demographic data and the Euthanasia Attitude Scale, which assesses attitudes towards euthanasia, were used for data collection. The mean (standard deviation) of the EAS were 74.62 (14.33). The Cronbach’s alpha was 0.944 and the confirmatory factor analysis to investigate the validity of the EAS scale, after modification effects, revealed an acceptable adjustment for the questionnaire. The GFI index was above 0.8 and close to 0.9, and the CFI index was above 0.9, which is the acceptable limit. The RMSEA index was acceptable below 0.08. The total Gr-EAS correlated with all five factors (Pearson r = 0.400−0.973, p < 0.001). According to the findings of this study, the Euthanasia Attitude Scale is a reliable and valid measure for assessing the attitudes toward euthanasia in Greek physicians. This Greek adaptation will be valuable in future studies examining the attitude of physicians towards euthanasia.

Odnos medicinskih sester do evtanazije

Uvod: Evtanazija je pojem, o katerem se mora razpravljati z vidika medicinskih, zdravstvenih in družboslovnih strok. Medicinske sestre so sestavni del zdravstvenih timov, zato je potrebno njihovo vključevanje v etične razprave o evtanaziji. Namen pregleda literature je predstaviti vidik evtanazije v povezavi z zdravstveno nego.Metode: Uporabljen je bil pregled literature, izveden v podatkovnih bazah COBIB.SI, CIHAHL in PubMed od 1. 11. 2020 do 1. 12. 2020. Iskanje je potekalo z uporabo ključnih besed: »evtanazija«, »zdravstvena nega«, v angleškem jeziku s kombinacijo ključnih besed: »attitudes«, »euthanasia« in »nursing«. Potek pregleda literature je prikazan z diagramom PRISMA. Kakovost virov, vključenih v končno analizo, je bila ocenjena s pomočjo hierarhije dokazov. Rezultati so bili sintetizirani z uporabo tematske analize.Rezultati: Izmed 138 virov je bilo v končno analizo vključenih enaindvajsetih člankov. Medicinske sestre so navajale naklonjen, kot tudi nenaklonjen odnos ter prisotnost etičnih dilem v povezavi z evtanazijo. Naklonjen odnos medicinskih sester do evtanazije se kaže v primerih neobvladljivih bolečin, neznosnega trpljenja in neozdravljivih bolezni, nenaklonjen pa v povezavi z nekaterimi demografskimi in kulturnimi značilnostmi medicinskih sester, upoštevanjem načel sočutne oskrbe in spoštovanjem vrednosti človekovega življenja.Diskusija in zaključek: Ugotovitve raziskave prispevajo prepoznati odnos medicinskih sester do evtanazije ter nekatere etične dileme v povezavi z evtanazijo. Potrebno bi bilo izvesti podrobne preglede etičnih dilem in moralnih stisk, ki se pojavljajo v povezavi z evtanazijo in zdravstveno nego.

Dying like a dog: the convergence of concepts of a good death in human and veterinary medicine

Standard views of good death in human and veterinary medicine considerably differ from one another. Whereas the good death ideal in palliative medicine emphasizes the positive aspects of non-induced dying, veterinarians typically promote a quick and painless killing with the aim to end suffering. Recent developments suggest a convergence of both professions and professional attitudes, however. Palliative physicians are confronted with patients wishing to be 'put to sleep', while veterinarians have begun to integrate principles and practices from hospice care. We will argue that the discourses on good human and animal deaths are not distinct, but that they interact and influence each other. On the one hand, veterinary medicine adapts techniques like chemotherapy or sedation from palliative end-of-life care. On the other hand, philosophers, veterinarians, pet owners, patients and the general public alike make certain assumptions about the (dis)analogy of human and animal dying or killing. Unfortunately, these interactions have only scarcely been reflected normatively, especially on the part of human medicine. Conflicts and misattributions with potential serious negative consequences for the (animal and human) patients' wellbeing are provoked. For these reasons, palliative physicians and veterinarians are invited to engage in the debate around human and animal end-of-life care.

Medical Aid in Dying: What Every Nurse Needs to Know

ABSTRACT

The number of U.S. states legalizing medical aid in dying for patients with terminal diseases and survival prognoses of six months or less is increasing. At press time, 10 states and the District of Columbia have legalized such aid. But because terminal illnesses without clear prognoses are not covered under these laws, some patients are forced to seek medical aid in dying outside the country.The nurse's role regarding aid in dying is poorly defined, and must be clarified. Currently, nurses and other providers have many misconceptions and fears about providing patients and families with the relevant education. Nurses need to have accurate knowledge and understanding of aid in dying, so they can advocate for those requesting this option; ensure equitable access; and provide them with guidance, support, and resources. An interdisciplinary approach is essential.This article provides background information on aid in dying in the United States, discusses the nurse's role, offers an illustrative case report, and addresses nursing implications.

Neuropalliative care: Defining an emerging field

Palliative care is increasingly becoming an established part of medical care, providing the holistic assessment and management of the person at the center of care-physical, psychological, social, and spiritual. This had originally been primarily provided for people with terminal cancers but in the last 50 years, this care has extended to caring for people with issues throughout disease progression and for all diagnoses, including neurologic diseases. Palliative care in fact is now included within guidelines and standards for many neurologic diseases. Palliative care may be delivered as an approach provided by all health and social care professionals; by focused care provided within neurology; and through the involvement of specialist palliative care and neuropalliative care for more complex issues. The education of neurologists and palliative care specialists is essential to enable all to be aware of the issues faced by patients and their families and provide adequate support for patients, families, and healthcare professionals. In this way, the quality of life can be maintained as much as possible and patients are able to die with as little distress as possible, with their families and carers supported.

"Reflection and soul searching": Negotiating nursing identity at the fault lines of palliative care and medical assistance in dying

Authorities within the field of palliative care frequently espouse that assisted death is - and must remain - separate from palliative care. This fault line, between palliative care and assisted death, has important implications for how we enact end-of-life care, particularly in jurisdictions where assisted death is legal. And yet little is known about how direct-care clinicians providing palliative care navigate this demarcation in everyday practice. This qualitative study reports on semi-structured interviews with 22 palliative care nurses from across Canada, where assisted death was legalized in 2016. Although a minority of participants did express categorical opinions around the (non) legitimacy of assisted death as an ethical end-of-life care option, most engaged in an ongoing and sometimes painful process of questioning and self-examination. Their ethical reflections were more nuanced than simply dismissing MAiD as incompatible with palliative care philosophy; yet this idea of incompatibility weighed heavily as they reasoned through their experiences and questioned their own perspectives. Nurses described grappling with the finality of assisted death, which contradicts their belief in the telos of palliative care; when adequately resourced, palliative care should be available to support people to live well before death. At the same time, commitment to important palliative care values such as the non-abandonment of dying people and respecting peoples' individual end-of-life choices reveal the possibility of overlap between the ethos of assisted death and that of palliative care nursing. Drawing on scholarship in feminist ethics, our study sheds light on the moral identity work that assisted dying catalyzes amongst palliative care nurses. We highlight what is at stake for them as they navigate a delicate tension in responding ethically to patients whose suffering motivates an interest in assisted death, from within a wider professional collective that upholds a master narrative about the incompatibility of assisted death and palliative care.

Social determinants of health and slippery slopes in assisted dying debates: lessons from Canada

The question of whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying has recently come to the fore in debates about the legalisation of assisted dying. For example, it was central to critiques of the 2021 amendments made to Canada's assisted dying law. The question of whether changes to a country's assisted dying legislation lead to descents down slippery slopes has also come to the fore-as it does any time a jurisdiction changes its laws. We explore these two questions through the lens of Canada's experience both to inform Canada's ongoing discussions and because other countries will confront the same questions if they contemplate changing their assisted dying law. Canada's Medical Assistance in Dying (MAiD) law has evolved through a journey from the courts to Parliament, back to the courts, and then back to Parliament. Along this journey the eligibility criteria, the procedural safeguards, and the monitoring regime have changed. In this article, we focus on the eligibility criteria. First, we explain the evolution of the law and what the eligibility criteria were at the various stops along the way. We then explore the ethical justifications for Canada's new criteria by looking at two elements of the often-corrosive debate. First, we ask whether problems with the social determinants of health that might impact decision-making justify denying eligibility for assisted dying of decisionally capable people with mental illnesses and people with disabilities as their sole underlying medical conditions. Second, we ask whether Canada's journey supports slippery slope arguments against permitting assisted dying.

Hospice care providers experiences of grappling with medical assistance in dying in a hospice setting: a qualitative descriptive study

Background

Rapid implementation of Medical Assistance in Dying (MAiD) across care settings has challenged providers and organizations, including hospices, to develop and implement new modes of practice. The aim of this study was to examine the effects that legalization of MAiD has had on hospice care provider roles within the non-provider context.

Methods

Eight in-depth semi-structured interviews were conducted and a qualitative descriptive approach used to examine hospice care providers experiences in a small western Canadian city. In the study context, patients who choose MAiD are cared for until immediately prior to the procedure when they are transferred off-site to undergo MAiD. Inductive and thematic analyses were undertaken.

Results

Participants experienced practical, philosophical, and professional challenges. Despite the overwhelming desire to support patient autonomy and decision-making, some interpreted patient choice for MAiD as rejection of the natural death experience at the hospice. Patient choice for MAiD initiated a new and different pathway of end-of-life care. While participants felt uncertain how best to support patients undergoing MAiD, they shared mixed optimism on how their care provider roles were evolving as their level of experience broadened. While implementation of MAiD was rapid, the introduction of practical and professional supports has remained slow to materialize, leaving many providers to navigate their own personal and professional positions and practices.

Conclusion

Care providers require a multi-faceted range of clinical, legal, and logistical supports at the practice, organizational, and health system levels, to facilitate care delivery to those requesting and undergoing MAiD and to promote coordinated and holistic patient-centered care. The different pathway for those who chose MAiD may lead care providers to struggle with relational challenges and interpersonal unease. Further research may address how to support those undergoing MAiD within the hospice context.

Impact of Medical Assistance in Dying on palliative care: A qualitative study

BACKGROUND

Medical Assistance in Dying comprises interventions that can be provided by medical practitioners to cause death of a person at their request if they meet predefined criteria. In June 2016, Medical Assistance in Dying became legal in Canada, sparking intense debate in the palliative care community.

AIM

This study aims to explore the experience of frontline palliative care providers about the impact of Medical Assistance in Dying on palliative care practice.

DESIGN

Qualitative descriptive design using semi-structured interviews and thematic analysis.

SETTINGS/PARTICIPANTS

We interviewed palliative care physicians and nurses who practiced in settings where patients could access Medical Assistance in Dying for at least 6 months before and after its legalization. Purposeful sampling was used to recruit participants with diverse personal views and experiences with assisted death. Conceptual saturation was achieved after interviewing 23 palliative care providers (13 physicians and 10 nurses) in Southern Ontario.

RESULTS

Themes identified included a new dying experience with assisted death; challenges with symptom control; challenges with communication; impact on palliative care providers personally and on their relationships with patients; and consumption of palliative care resources to support assisted death.

CONCLUSION

Medical Assistance in Dying has had a profound impact on palliative care providers and their practice. Communication training with access to resources for ethical decision-making and a review of legislation may help address new challenges. Further research is needed to understand palliative care provider distress around Medical Assistance in Dying, and additional resources are necessary to support palliative care delivery.

Impact of Applying Palliative Care on Symptoms and Survival of Patients with Advanced Chronic Disease Admitted to the Emergency Department

Introduction:

In the emergency department, there is a need to provide palliative care; however, they are not usually administered. The present study evaluates the evolution of the intensity of the symptoms when applying palliative care, in adult patients with advanced chronic disease admitted to the emergency room, and compares survival between those who receive this care and those who do not.

Materials and Methods:

A clinical intervention study was conducted including patients older than 18 years with advanced chronic disease admitted to the emergency room with an indication of palliative support according to the Supportive and Palliative Care Indicators Tool 2015. Three hundred and seven patients were studied (74 in the intervention group and 233 in the group not intervened). In the intervention group, the intensity of pre- and postintervention symptoms was compared (Wilcoxon test). The survival of both the groups were then compared (logrank test).

Results:

There was a significant decrease in pain and dyspnea at 24 and 48 h postintervention (P < 0.01), respectively, while drowsiness increased significantly at 24 h (P < 0.01) but did not change at 48 h (P = 0.38). Excluding patients with better functional status, there was less survival at 3 months in the intervention group (P = 0.01).

Conclusions:

Dyspnea and pain decreased with the application of palliative care but not drowsiness. Survival in the intervention group was lower than in the nonintervention group. However, the reason for providing palliative care is to relieve suffering at the end of life.

Prevalence of palliative sedation in the State of São Paulo: an emerging medical demand

Objective

To investigate the prevalence of palliative sedation use and related factors.

Methods

An observational study based on data collected via electronic questionnaire comprising 23 close-ended questions and sent to physicians living and working in the state of São Paulo. Demographic data, prevalence and frequency of palliative sedation use, participant’s familiarity with the practice and related motivating factors were analyzed. In order to minimize memory bias, questions addressing use frequency and motivating factors were limited to the last year prior to survey completion date. Descriptive statistics were used to summarize data.

Results

In total, 20,168 e-mails were sent and 324 valid answers obtained, resulting in 2% adherence. The overall prevalence of palliative sedation use over the course of professional practice was 68%. However, only 48% of respondents reported having used palliative sedation during the last year, primarily to relieve pain (35%). The frequency of use ranged from one to six times (66%) during the study period and the main reason for not using was the lack of eligible patients (64%). Approximately 83% of physicians felt comfortable using palliative sedation but only 26% reported having specific academic training in this field.

Conclusion

The prevalence of palliative sedation use is high, the primary indication being pain relief. However, frequency of use is low due to lack of eligible patients.

Dying individuals and suffering populations: applying a population-level bioethics lens to palliative care in humanitarian contexts: before, during and after the COVID-19 pandemic

BACKGROUND

Humanitarian crises and emergencies, events often marked by high mortality, have until recently excluded palliative care-a specialty focusing on supporting people with serious or terminal illness or those nearing death. In the COVID-19 pandemic, palliative care has received unprecedented levels of societal attention. Unfortunately, this has not been enough to prevent patients dying alone, relatives not being able to say goodbye and palliative care being used instead of intensive care due to resource limitations. Yet global guidance was available. In 2018, the WHO released a guide on 'Integrating palliative care and symptom relief into the response to humanitarian emergencies and crises'-the first guidance on the topic by an international body.

AIMS

This paper argues that while a landmark document, the WHO guide took a narrowly clinical bioethics perspective and missed crucial moral dilemmas. We argue for adding a population-level bioethics lens, which draws forth complex moral dilemmas arising from the fact that groups having differential innate and acquired resources in the context of social and historical determinants of health. We discuss dilemmas concerning: limitations of material and human resources; patient prioritisation; euthanasia; and legacy inequalities, discrimination and power imbalances.

IMPLICATIONS

In parts of the world where opportunity for preparation still exists, and as countries emerge from COVID-19, planners must consider care for the dying. Immediate steps to support better resolutions to ethical dilemmas of the provision of palliative care in humanitarian and emergency contexts will require honest debate; concerted research effort; and international, national and local ethical guidance.

Options of Last Resort: Palliative Sedation, Physician Aid in Dying, and Voluntary Cessation of Eating and Drinking

Some patients with terminal and degenerative illnesses request assistance to hasten death when suffering is refractory to palliative care, or they strongly desire to maximize their autonomy and dignity and minimize suffering. Palliative sedation (PS), voluntarily stopping eating and drinking (VSED), and physician-assisted death (PAD) are possible options of last resort. A decision to choose PS can be made by an informed surrogate decision maker, whereas intact decision-making capacity is required to choose VSED or PAD. For all palliative treatments of last resort, the risk of harm is minimized by the use of checklists, and establishment of policies and procedures.

Early experience with medical assistance in dying in Ontario, Canada: a cohort study

BACKGROUND

Medical assistance in dying (MAiD) was legalized across Canada in June 2016. Some have expressed concern that patient requests for MAiD might be driven by poor access to palliative care and that social and economic vulnerability of patients may influence access to or receipt of MAiD. To examine these concerns, we describe Ontario's early experience with MAiD and compare MAiD decedents with the general population of decedents in Ontario.

METHODS

We conducted a retrospective cohort study comparing all MAiD-related deaths with all deaths in Ontario, Canada, between June 7, 2016, and Oct. 31, 2018. Clinical and demographic characteristics were collected for all MAiD decedents and compared with those of all Ontario decedents when possible. We used logistic regression analyses to describe the association of demographic and clinical factors with receipt of MAiD.

RESULTS

A total of 2241 patients (50.2% women) were included in the MAiD cohort, and 186 814 in the general Ontario decedent cohort. Recipients of MAiD reported both physical (99.5%) and psychologic suffering (96.4%) before the procedure. In 74.4% of cases, palliative care providers were involved in the patient's care at the time of the MAiD request. The statutory 10-day reflection period was shortened for 26.6% of people. Compared with all Ontario decedents, MAiD recipients were younger (mean 74.4 v. 77.0 yr, standardized difference 0.18);, more likely to be from a higher income quintile (24.9% v. 15.6%, standardized difference across quintiles 0.31); less likely to reside in an institution (6.3% v. 28.0%, standardized difference 0.6); more likely to be married (48.5% v. 40.6%) and less likely to be widowed (25.7% v. 35.8%, standardized difference 0.34); and more likely to have a cancer diagnosis (64.4% v. 27.6%, standardized difference 0.88 for diagnoses comparisons).

INTERPRETATION

Recipients of MAiD were younger, had higher income, were substantially less likely to reside in an institution and were more likely to be married than decedents from the general population, suggesting that MAiD is unlikely to be driven by social or economic vulnerability. Given the high prevalence of physical and psychologic suffering, despite involvement of palliative care providers in caring for patients who request MAiD, future studies should aim to improve our understanding and treatment of the specific types of suffering that lead to a MAiD request.

Continuing the conversation about medical assistance in dying

In their summary and critique, Gamble, Gamble, and Pruski mischaracterise both the central arguments and the primary objectives of our original paper. Our paper does not provide an ethical justification for paediatric Medical Assistance in Dying (MAID) by comparing it with other end of life care options. In fact, it does not offer arguments about the permissibility of MAID for capable young people at all. Instead, our paper focuses on the ethical questions that emerged as we worked to develop a policy for responding to MAID requests at our tertiary paediatric institution. Following the Supreme Court of Canada's recent decriminalisation of MAID, our hospital needed to answer immediate on-the-ground questions such as: 'What are we going to do if an 18-year-old patient in our care requested MAID today, as is now their legal right? How should we protect their privacy? What is the best way to ensure patients are informed when making these decisions?' On these important questions, Gamble, Gamble, and Pruskiare silent.

Investigating palliative care nurse attitudes towards medical assistance in dying: An exploratory cross-sectional study

AIM

To investigate palliative care nurse attitudes towards medical assistance in dying.

DESIGN

An exploratory cross-sectional study design.

METHODS

A mailed letter recruited participants with data collection occurring on a secure online survey platform between November 2017-February 2018. Data analyses included descriptive and bivariate statistics and stepwise linear regression.

RESULTS

Palliative care nurse attitudes towards medical assistance in dying were explained by perceived expertise in the social domain of palliative care, personal importance of religion/faith, professional importance of religion/faith, and nursing designation.

CONCLUSION

This study reveals the perceived importance of religion, versus religious affiliation alone, as significant in influencing provider attitudes towards assisted dying. Further research is needed to understand differences in attitudes between Registered Nurses and Registered Practical Nurses and how the social domain of palliative care influences nurse attitude.

IMPACT

Organizations must prioritize nursing input, encourage open interprofessional dialogue and provide support for ethical decision-making, practice decisions, and conscientious objection surrounding medical assistance in dying. Longitudinal nursing studies are needed to understand the impact of legislation on quality and person-centred end-of-life care and the emotional well-being/retention of palliative care nurses.

Medical assistance in dying: implications for health systems from a scoping review of the literature

Objective

Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems.

Methods

We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers.

Results

The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail.

Conclusion

Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.

The spectrum of end of life care: an argument for access to medical assistance in dying for vulnerable populations

Medical assistance in dying (MAiD) was legalized by the Supreme Court of Canada in June 2016 and became a legal, viable end of life care (EOLC) option for Canadians with irremediable illness and suffering. Much attention has been paid to the balance between physicians' willingness to provide MAiD and patients' legal right to request medically assisted death in certain circumstances. In contrast, very little attention has been paid to the challenge of making MAiD accessible to vulnerable populations. The purpose of this paper was to examine the extant literature and resources that are available on the provision of MAiD in Canada. We found that the provision of EOLC in Canada offers insufficient access to palliative and EOLC options for Canadians and that vulnerable Canadians experience disproportional barriers to accessing these already limited resources. Consequently, we argue that palliative care, hospice care and MAiD must be considered a spectrum of EOLC that is inclusive and accessible to all Canadians. We conclude by imploring Canadian healthcare professionals, policy makers and legislators to consider MAiD as a viable EOLC option for all Canadians.

Medical Assistance in Dying at a paediatric hospital

This article explores the ethical challenges of providing Medical Assistance in Dying (MAID) in a paediatric setting. More specifically, we focus on the theoretical questions that came to light when we were asked to develop a policy for responding to MAID requests at our tertiary paediatric institution. We illuminate a central point of conceptual confusion about the nature of MAID that emerges at the level of practice, and explore the various entailments for clinicians and patients that would flow from different understandings. Finally, we consider the ethical challenges of building policy on what is still an extremely controversial social practice. While MAID is currently available to capable patients in Canada who are 18 years or older-a small but important subsection of the population our hospital serves-we write our policy with an eye to the near future when capable young people may gain access to MAID. We propose that an opportunity exists for MAID-providing institutions to reduce social stigma surrounding this practice, but not without potentially serious consequences for practitioners and institutions themselves. Thus, this paper is intended as a road map through the still-emerging legal and ethical landscape of paediatric MAID. We offer a view of the roads taken and considered along the way, and our justifications for travelling the paths we chose. By providing a record of our in-progress thinking, we hope to stimulate wider discussion about the issues and questions encountered in this work.

Of dilemmas and tensions: a qualitative study of palliative care physicians' positions regarding voluntary active euthanasia in Quebec, Canada

OBJECTIVES

In 2015, the Province of Quebec, Canada passed a law that allowed voluntary active euthanasia (VAE). Palliative care stakeholders in Canada have been largely opposed to euthanasia, yet there is little research about their views. The research question guiding this study was the following: How do palliative care physicians in Quebec position themselves regarding the practice of VAE in the context of the new provincial legislation?

METHODS

We used interpretive description, an inductive methodology to answer research questions about clinical practice. A total of 18 palliative care physicians participated in semistructured interviews at two university-affiliated hospitals in Quebec.

RESULTS

Participants positioned themselves in opposition to euthanasia. Their justifications were framed within their professional commitment to not hasten death, which sat in tension with the value of patients' autonomy to choose how to die. Participants described VAE as unacceptable if it impeded opportunities to evaluate and alleviate suffering. Further, they contested government rhetoric that positioned VAE as a way to improve end-of-life care. Participants felt that VAE would diminish the potential of palliative care to relieve suffering. Dilemmas were apparent in their narratives, about reconciling respect for patient autonomy with broader palliative care values, and the value of accompanying and not abandoning patients who make requests for VAE while being committed to neither prolonging nor hastening death.

CONCLUSIONS

This study provides insight into nuanced positions of experienced palliative care physicians in Quebec and confirms expected tensions between an important stakeholder and the practice of VAE as guided by the new legislation.

Physician-Assisted Suicide and Euthanasia

Conclusions:

Physicians have a duty to eliminate pain and suffering, not the person with the pain and suffering. Solutions for suffering lie in improving palliative care and social conditions and addressing the reasons for PAS-E requests. They should not include changing medical practice to allow PAS-E.

Changes in attitudes towards hastened death among Finnish physicians over the past sixteen years

Background

The ethics of hastened death are complex. Studies on physicians’ opinions about assisted dying (euthanasia or assisted suicide) exist, but changes in physicians’ attitudes towards hastened death in clinical decision-making and the background factors explaining this remain unclear.

The aim of this study was to explore the changes in these attitudes among Finnish physicians.

Methods

A questionnaire including hypothetical patient scenarios was sent to 1182 and 1258 Finnish physicians in 1999 and 2015, respectively. Two scenarios of patients with advanced cancer were presented: one requesting an increase in his morphine dose to a potentially lethal level and another suffering a cardiac arrest. Physicians’ attitudes towards assisted death, life values and other background factors were queried as well. The response rate was 56%.

Results

The morphine dose was increased by 25% and 34% of the physicians in 1999 and 2015, respectively (p < 0.001). Oncologists approved the increase most infrequently without a significant change between the study years (15% vs. 17%, p = 0.689). Oncological specialty, faith in God, female gender and younger age were independent factors associated with the reluctance to increase the morphine dose. Euthanasia, but not assisted suicide, was considered less reprehensible in 2015 (p = 0.008). In both years, most physicians (84%) withheld cardiopulmonary resuscitation.

Conclusion

Finnish physicians accepted the risk of hastening death more often in 2015 than in 1999. The physicians’ specialty and many other background factors influenced this acceptance. They also regarded euthanasia as less reprehensible now than they did 16 years ago.

The views of adults with Huntington's disease on assisted dying: A qualitative exploration

BACKGROUND

Assisted dying is frequently debated publicly and research often includes the views of health professionals on this issue. However, the views of people with life-limiting conditions, for whom this issue is likely to have a different resonance, are less well represented.

AIM

The purpose of this study was to explore the views of people who live with the inevitability of developing Huntington's disease, a genetically transmitted disease which significantly limits life, on assisted dying.

DESIGN

Using thematic analysis methodology, individual semi-structured interviews were conducted.

SETTING/PARTICIPANTS

Seven participants (five women and two men) who were gene positive for Huntington's disease took part in the study.

RESULTS

Four themes were extracted: (1) autonomy and kindness in assisted dying: the importance of moral principles; (2) Huntington's disease threatens life and emphasises issues relating to death; (3) dilemmas in decision-making on assisted dying: "There are no winners" and (4) the absence of explicit discussion on dying and Huntington's disease: "Elephants in the room".

CONCLUSIONS

Our findings suggest that talking to patients about assisted death may not cause harm and may even be invited by many patients with Huntington's disease. The perspectives of those who live with Huntington's disease, especially given its extended effects within families, add significant clinical and theoretical insights.

Japanese physicians’ experiences of terminally ill patients voluntarily stopping eating and drinking: a national survey

Objectives

Voluntarily stopping eating and drinking (VSED) could be regarded as a patients’ own non-treatment decision that hastens death, which involves patients voluntarily forgoing food and liquid until death. The aims of this study were to investigate the experience of home hospice physicians and palliative care specialists who care for patients during VSED in Japan, and their opinions on continuous deep sedation (CDS) as a means to relieve patient symptoms during VSED.

Methods

219 home hospice physicians and 695 palliative care specialists across Japan were surveyed by mail questionnaire in 2016.

Results

A total of 571 (62%) responses were analysed. A total of 185 (32%) had experience of patients who selected VSED. In response to questions about CDS to provide relief to patients during VSED, the number of physicians who replied that CDS was acceptable was 88 (15%).

Conclusions

In Japan, 32% of physicians surveyed replied that they had experience of caring for patients during VSED in a clinical setting and 15% considered CDS acceptable.