“It is still intense and not unambiguous.” Nurses' experiences in the euthanasia care process 15 years after legalisation

Nurses under fire: Insights from testimonies of community nurses and midwives in nonhospital settings in the southern Israel conflict zone

Nurses-with or without prehospital care training-may find themselves delivering immediate care to injured individuals outside a healthcare facility, sometimes even in situations where their own life is at risk. This study explores the experiences of community nurses and midwives who provided immediate care during the Hamas militant movement's attack in southern Israel. The researchers collected and analyzed eight nurse and midwife survivors' testimonies published in digital media to gain a deeper understanding of their perspectives. Through qualitative content analysis, common themes, patterns, and insights were identified. The study aimed to contribute valuable knowledge in this field and followed the Consolidated Criteria for Reporting Qualitative Research (COREQ) checklist for methodological rigor. Two themes emerged from the testimonies, focusing on the nurses' swift realization of necessary action under fire and resilience and ingenuity in practice. Despite lacking training and resources, the nurses professionally assessed the situation and improvised creative solutions to care for the wounded. Although they had no prehospital emergency care background, community nurses and midwives were able to respond effectively, providing lifesaving care. The findings highlight the nurses' resilience, adaptability, and dedication in unprecedented situations. However, the study also emphasizes the importance of providing all nurses with baseline prehospital care training and structured planning of this care to empower them to deliver optimal patient care in uncertain and dangerous conditions, especially in and around conflict and disaster zones.

Relatives' needs in terms of bereavement care throughout euthanasia processes: A qualitative study

AIM

To explore relatives' needs in terms of bereavement care during euthanasia processes, how healthcare providers respond to these needs, and the degree of commonality between relatives' and healthcare providers' reports.

DESIGN

A phenomenological design was employed, utilising reflexive thematic analysis to examine interviews conducted with relatives (N = 19) and healthcare providers (N = 47).

RESULTS

Relatives' needs throughout euthanasia processes are presented in five main themes and several subthemes, with similar findings between both sets of participants. Although relatives infrequently communicated their needs explicitly to healthcare providers, they appreciated it when staff proactively met their needs. Healthcare providers aimed to assist with the relatives' grief process by tending to their specific needs. However, aftercare was not consistently offered, but relatives did not have high expectations for professional follow-up care.

CONCLUSION

Our research offers important directions for healthcare professionals, empowering them to provide needs-based bereavement care during euthanasia processes. Moreover, it emphasises the importance of recognising the unique needs of relatives and proactively addressing them in the period before the loss to positively contribute to relatives' grief process.

IMPLICATIONS FOR THE PROFESSION AND/OR PATIENT CARE

Insights into relatives' needs in the context of euthanasia. Good practices on how healthcare providers can attend to relatives' needs before, during and after the loss IMPACT: Current literature and guidelines on needs-based bereavement care in the context of euthanasia and, more generally, assisted dying, are limited. These findings provide concrete directions for practice in supporting (nearly) bereaved relatives in the context of euthanasia, potentially mitigating adverse health outcomes.

REPORTING METHOD

Standards for Reporting Qualitative Research (SRQR checklist).

PATIENT OR PUBLIC CONTRIBUTION

Relatives of deceased cancer patients were involved in the conduct of the study.

"More support, less distress?": Examining the role of social norms in alleviating practitioners' psychological distress in the context of assisted dying services

This study explores how providing assisted dying services affects the psychological distress of practitioners. It investigates the influence of professional norms that endorse such services within their field. Study 1 included veterinarians (N = 137, 75.2% female, Mage = 43.1 years, SDage = 12.7 years), and Study 2 health practitioner students (N = 386, 71.0% female, Mage = 21.0 years, SDage = 14.4 years). In both studies, participants indicated their degree of psychological distress following exposure to scenarios depicting assisted dying services that were relevant to their respective situations. In Study 1, we found that higher willingness to perform animal euthanasia was associated with lower distress, as were supportive norms. In Study 2, a negative association between a greater willingness to perform euthanasia and lower psychological distress occurred only when the provision of such services was supported by professional norms. In conclusion, psychological distress is buffered by supportive professional norms.

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

OBJECTIVES

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

BACKGROUND

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

DESIGN

A qualitative descriptive approach was undertaken.

METHODS

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

FINDINGS

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

CONCLUSION

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

Nursing students' attitude toward euthanasia following its legalization in Spain

BACKGROUND

Euthanasia is a controversial practice in many countries. Since Spain's Euthanasia Law came into effect on March 24, 2021, healthcare providers have faced a new challenge since they must inform patients, provide care, accompany them, and implement the law. It also represents a new stumbling block at universities, which must adapt to regulatory changes and educate future professionals accordingly. Little is known about the attitude of nursing students in Spain toward euthanasia since this law was implemented.

OBJECTIVE

This study aims to answer the following research questions: What is the attitude of nursing students toward euthanasia? What factors influence this attitude?

RESEARCH DESIGN

A cross-sectional study was conducted using an online questionnaire.

PARTICIPANTS AND RESEARCH CONTEXT

The study population comprised all nursing students at a public university in Barcelona (n = 444), Spain, during the 2022-2023 academic year. The validated Spanish version of the Euthanasia Attitude Scale was employed. A bivariate analysis was performed.

ETHICAL CONSIDERATIONS

The university Ethics Committee (CEEAH 6247) approved this study. All participating students signed an informed consent form. Participation was voluntary, and data anonymity and confidentiality were guaranteed.

RESULTS

Two hundred and forty-four nursing students responded to the questionnaire. The mean total score was 79.64. Participants with religious beliefs presented lower scores, indicating a more negative attitude toward euthanasia. Participants in their second, third, or fourth year of the nursing degree scored higher, demonstrating a more positive attitude.

CONCLUSIONS

The attitude of nursing students toward euthanasia was remarkably positive. Working on ethical content during the degree course and clinical practice are factors that help to develop a more positive attitude. In addition, nursing education should encourage professional aspects to prevail over religious beliefs in euthanasia situations.

Decision-making process regarding passive euthanasia: Theory of planned behavior framework

BACKGROUND

Nurses have an essential role in caring for end-of-life patients. Nevertheless, the nurse's involvement in the passive euthanasia decision-making process is insufficient and lower than expected.

OBJECTIVES

To explore factors associated with nurses' intention to be involved in non-treatment decisions (NTD) regarding passive euthanasia decision-making versus their involvement in the palliative care of patients requesting euthanasia, using the Theory of Planned Behavior (TPB) framework.

DESIGN

A cross-sectional study utilizing a random sample.

PARTICIPANTS AND RESEARCH CONTEXT

The study was conducted in one of the largest hospitals in Israel among 125 nurses employed in internal and surgical care wards. Data was collected through face-to-face interviews between March and April 2019.

METHOD

A closed structured questionnaire was developed according to TPB instructions. A paired sample t test and two multiple hierarchical regressions were conducted. Variance explained (R2) and the significance of F change were calculated for each regression. The study used the STROBE statement guideline.

ETHICAL CONSIDERATIONS

The study was approved by the hospital's Helsinki Committee (#20.11.2017).

FINDINGS

A paired sample t test revealed that nurses' involvement in the palliative care of patients requesting passive euthanasia was significantly higher than in NTD regarding euthanasia. Regression analyses revealed that nurses' position and attitudes explain their intention to be involved in decision-making; attitudes and perceived behavioral control explain nurses' intention to be involved in the care of patients requesting euthanasia.

CONCLUSIONS

According to the TPB, nurses' attitudes explained their intention to participate in decision-making regarding passive euthanasia. It is recommended to enhance open discussion of this complex issue to encourage nurses' willingness to participate in NTD decision-making regarding euthanasia.

Definition and validation of the nursing diagnosis label "wish to die": a research protocol

BACKGROUND

Euthanasia has been incorporated into the health services of seven countries. The legalisation of these practices has important repercussions for the competences of nurses, and it raises questions about their role. When a patient with advanced disease expresses a wish to die, what is expected of nurses? What are the needs of these patients, and what kind of care plan do they require? What level of autonomy might nurses have when caring for these patients? The degree of autonomy that nurses might or should have when it comes to addressing such a wish and caring for these patients has yet to be defined. Recognising the wish to die as a nursing diagnosis would be an important step towards ensuring that these patients receive adequate nursing care. This study-protocol aims to define and validate the nursing diagnosis wish to die in patients with advanced disease, establishing its defining characteristics and related factors; to define nursing-specific interventions for this new diagnosis.

METHODS

A prospective three-phase study will be carried out. Phase-A) Foundational knowledge: an umbrella review of systematic reviews will be conducted; Phase-B) Definition and validation of the diagnostic nomenclature, defining characteristics and related factors by means of an expert panel, a Delphi study and application of Fehring's diagnostic content validation model; Phase-C) Definition of nursing-specific interventions for the new diagnosis. At least 200 academic and clinical nurses with expertise in the field of palliative care or primary health care will be recruited as participants across the three phases.

DISCUSSION

The definition of the wish to die as a nursing diagnosis would promote greater recognition and autonomy for nurses in the care of patients who express such a wish, providing an opportunity to alleviate underlying suffering through nursing-specific interventions and drawing attention to the needs of patients with advanced disease. The new diagnosis would be an addition to nursing science and would provide a framework for providing care to people with advanced disease who express such a wish. Nurses would gain professional autonomy about identifying, exploring and responding clinically to such a wish.

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.

Relatives' Experiences of Being Involved in Assisted Dying: A Qualitative Study

Recent literature demonstrates an interdependence between relatives and healthcare providers throughout euthanasia processes. Yet, current guidelines and literature scarcely specify the interactions between healthcare providers and bereaved relatives. The aim of this work consisted of providing an insight into bereaved relatives' experiences (1) of being involved in euthanasia processes and (2) of their interactions with healthcare providers before, during, and after the euthanasia. The research process was guided by the principles of constructivist grounded theory. Nineteen Dutch-speaking bereaved relatives of oncological patients, who received euthanasia at home or in a hospital less than 24 months ago, participated via semi-structured interviews. These interviews were conducted between May 2021 and June 2022. Due to the intensity of euthanasia processes, relatives wanted to be involved as early as possible, in order to receive time, space, and access to professionals' support whilst preparing themselves for the upcoming loss of a family member with cancer. Being at peace with the euthanasia request facilitated taking a supportive attitude, subsequently aiding in achieving a serene atmosphere. A serene atmosphere facilitated relatives' grief process because it helped them in creating and preserving good memories. Relatives appreciated support from healthcare providers, as long as overinvolvement on their part was not occurring. This study advocates for a relational approach in the context of euthanasia and provides useful complements to the existing euthanasia guidelines.

Moral uncertainty and distress about voluntary assisted dying prior to legalisation and the implications for post-legalisation practice: a qualitative study of palliative and hospice care providers in Queensland, Australia

OBJECTIVES

There is little research on moral uncertainties and distress of palliative and hospice care providers (PHCPs) working in jurisdictions anticipating legalising voluntary assisted dying (VAD). This study examines the perception and anticipated concerns of PHCPs in providing VAD in the State of Queensland, Australia prior to legalisation of the practice in 2021. The findings help inform strategies to facilitate training and support the health and well-being of healthcare workers involved in VAD.

DESIGN

The study used a qualitative approach to examine and analyse the perception and anticipated concerns of PHCPs regarding challenges of providing assisted dying in Queensland. Fourteen PHCPs were recruited using a purposive sampling strategy to obtain a broad representation of perspectives including work roles, geographical locations and workplace characteristics. Data were collected via one in-depth interview per participant. The transcripts were coded for patterns and themes using an inductive analysis approach following the tradition of Grounded Theory.

SETTING

The study was conducted in hospital, hospice, community and residential aged care settings in Queensland, Australia. These included public and private facilities, secular and faith-based facilities, and regional/rural and urban facilities.

PARTICIPANTS

Interviews were conducted with fourteen PHCPs: 10 nurses and 4 physicians; 11 female and 3 male. The median number of years of palliative care practice was 17, ranging from 2 to 36 years. For inclusion, participants had to be practising palliative and hospice care providers.

RESULTS

PHCPs are divided on whether VAD should be considered part of palliative care. Expectations of moral distress and uncertainty about practising VAD were identified in five areas: handling requests, assessing patient capacity, arranging patient transfers and logistical issues, managing unsuccessful attempts, and dealing with team conflicts and stigma.

CONCLUSIONS

The possibility of having to practise VAD causes moral distress and uncertainty for some PHCPs. Procedural clarity can address some uncertainties; moral and psychological distress, however, remains a source of tension that needs support to ensure ongoing care of both patients and PHCPs. The introduction of VAD post-legalisation may present an occasion for further moral education and development of PHCPs.

Attitudes Toward and Experience With Assisted-Death Services and Psychological Implications for Health Practitioners: A Narrative Systematic Review

A narrative systematic review was conducted to review studies that examine mental health implications of involvement in assisted-death services among health practitioners. Qualitative and quantitative studies were included to understand health practitioners' attitudes and experiences with assisted dying services, as well as to identify the mental health consequences. We identified 18 articles from 1591 articles drawn from seven major scientific databases (i.e., PubMed, MEDLINE, CINAHL, PsycINFO, Embase, Web of Science, and Scopus). Two raters independently evaluated the exclusion and inclusion decisions of the articles and examined methodological flaws in the selected articles. We found that engagement in assisted death services were not reliably associated with mental health outcomes such as anxiety and moral distress. Both positive and negative outcomes were reported, and psychological outcomes for practitioners were shown to vary based on factors including social support for health practitioners' views; their perceived capacity to care for the patients; and legislation.

Nurses' experiences of supporting patients requesting voluntary assisted dying: A qualitative meta-synthesis

AIM

Describe the reported lived experiences of nurses who have participated at any stage of voluntary assisted dying (VAD), from the initial request to the end of life.

DESIGN

A qualitative meta-synthesis.

DATA SOURCES

Databases searched were CINAHL, MEDLINE, Emcare, Scopus and PsycInfo. The search was undertaken in September 2021 with no date limitations. Qualitative studies were considered if published in English, reported primary data analysis of nurses' experiences who had been involved in VAD and reported direct quotes from nurses.

REVIEW METHODS

Qualitative studies meeting the selection criteria were critically appraised, then an open card-sort method was applied. Quotes from nurses were organized to group similar experiences, constructing themes and metaphors across studies as a new understanding of nurses' experiences of VAD.

RESULTS

Eight studies were included. Three major themes were constructed: An orderly procedure, reflecting the need for structure to feel adequately prepared; A beautiful death, reflecting the autonomy the patient exercised when choosing VAD facilitated an exceptionally positive death; and Psychological and emotional impact, where nurses recognized the emotional and ethical weight that they carried for themselves and the team when undertaking VAD.

CONCLUSION

Nurses may benefit from clear policy, supervision and communication training to support them as countries transition to providing VAD services. Policy provides nurses with confidence that they are undertaking the steps of VAD correctly and provides a layer of emotional protection. Communication training specific to VAD is necessary to prepare nurses to recognize their own emotional experiences when responding to the needs of the patient and their family.

IMPACT

VAD is increasingly becoming a legal option that nurses are encountering in their professional practice. Understanding nurses' experiences of being involved in VAD is required to support nurses in countries where VAD is becoming available to prepare professionally and psychologically.

Paradoxes, nurses' roles and Medical Assistance in Dying: A grounded theory

BACKGROUND

In June 2016, the Parliament of Canada passed federal legislation allowing eligible adults to request Medical Assistance in Dying (MAID). Since its implementation, there likely exists a degree of hesitancy among some healthcare providers due to the law being inconsistent with personal beliefs and values. It is imperative to explore how nurses in Quebec experience the shift from accompanying palliative clients through "a natural death" to participating in "a premeditated death."

RESEARCH QUESTION/AIM/OBJECTIVES

This study aims to explore how Quebec nurses personally and professionally face the new practice of MAID and their role evolution.

RESEARCH DESIGN

A grounded theory design was used.

PARTICIPANTS AND RESEARCH CONTEXT

We recruited 37 nurses who participated in or coordinated at least one MAID. Semi-structured interviews and focus groups were conducted and audiotaped. Data collection and analysis followed Strauss and Corbin steps.

ETHICAL CONSIDERATIONS

Ethics approval was received from the investigator's affiliated University. Participants were informed regarding the research goal, signed a written consent, and were assigned pseudonyms.

FINDINGS/RESULTS

Results show that nurses experienced the wide range of paradoxe during MAID centering around the following eight elements: 1) confrontation abouth death, 2) choice, 3) time of death, 4) emotional load, 5) new Bill, 6) relationship with the person, 7) communication skills, and 8) healthcare setting. The shifting of views and values in this new role is presented by the contradiction of opposites.

CONCLUSIONS

A better understanding of the paradox experienced by nurses involved with MAID paves the way for the development of interventions.

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.

What's suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID)

BACKGROUND

Intolerable suffering is a common eligibility requirement for persons requesting assisted death, and although suffering has received philosophic attention for millennia, only recently has it been the focus of empirical inquiry. Robust theoretical knowledge about suffering is critically important as modern healthcare provides persons with different options at end-of-life to relieve suffering. The purpose of this paper is to present findings specific to the understanding and application of suffering in the context of MAID from nurses' perspectives.

METHODS

A longitudinal qualitative descriptive study using semi-structured telephone interviews. Inductive analysis was used to construct a thematic account. The study received ethical approval and all participants provided written consent.

RESULTS

Fifty nurses and nurse practitioners from across Canada were interviewed. Participants described the suffering of dying and provided insights into the difficulties of treating existential suffering and the iatrogenic suffering patients experienced from long contact with the healthcare system. They shared perceptions of the suffering that leads to a request for MAID that included the unknown of dying, a desire for predictability, and the loss of dignity. Eliciting the suffering story was an essential part of nursing practice. Knowledge of the story allowed participants to find the balance between believing that suffering is whatever the persons says it is, while making sure that the MAID procedure was for the right person, for the right reason, at the right time. Participants perceived that the MAID process itself caused suffering that resulted from the complexity of decision-making, the chances of being deemed ineligible, and the heighted work of the tasks of dying.

CONCLUSIONS

Healthcare providers involved in MAID must be critically reflective about the suffering histories they bring to the clinical encounter, particularly iatrogenic suffering. Further, eliciting the suffering stories of persons requesting MAID requires a high degree of skill; those involved in the assessment process must have the time and competency to do this important role well. The nature of suffering that patients and family encounter as they enter the contemplation, assessment, and provision of MAID requires further research to understand it better and develop best practices.

Navigating medical assistance in dying from Bill C-14 to Bill C-7: a qualitative study

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.

"I Am Okay With It, But I Am Not Going to Do It": The Exogenous Factors Influencing Non-Participation in Medical Assistance in Dying

Medical assistance in dying (MAID) processes are complex, shaped by legislated directives, and influenced by the discourse regarding its emergence as an end-of-life care option. Physicians and nurse practitioners (NPs) are essential in determining the patient's eligibility and conducting MAID provisions. This research explored the exogenous factors influencing physicians' and NPs' non-participation in formal MAID processes. Using an interpretive description methodology, we interviewed 17 physicians and 18 NPs in Saskatchewan, Canada, who identified as non-participators in MAID. The non-participation factors were related to (a) the health care system they work within, (b) the communities where they live, (c) their current practice context, (d) how their participation choices were visible to others, (e) the risks of participation to themselves and others, (f) time factors, (g) the impact of participation on the patient's family, and (h) patient-HCP relationship, and contextual factors. Practice considerations to support the evolving social contact of care were identified.

Conscientious objection to medical assistance in dying in rural/remote nursing

In 2016, the Supreme Court of Canada legalized medical assistance in dying in Canada. Similar to jurisdictions where this has been a more long-standing option for end-of-life care, the Supreme Court's decision in Canada included a caveat that no healthcare provider could be compelled to participate in medical assistance in dying. The Canadian Nurses Association, in alignment with numerous ethical guidelines for healthcare providers around the globe, maintains that nurses may opt out of participation in medical assistance in dying if they conscientiously object to this procedure. The realities of implementing medical assistance in dying are still unfolding. One area that has received little attention in the literature thus far is the ability of nurses who aid with, rather than administer, medical assistance in dying to conscientiously object. This is particularly significant in rural and remote areas of Canada where geographic dispersion and limited numbers of nursing staff create conditions that limit the ability to transfer care or call on a designated team. Exercising conscientious objection to medical assistance in dying in rural and remote areas, by way of policies developed with an urban focus, is one example of how the needs of rural nurses and patients may not be met, leading to issues of patient access to medical assistance in dying and retention of nursing staff. To illustrate the complexities of nurses' conscientious objection to medical assistance in dying in a rural setting, we apply an ethical decision-making framework to a hypothetical case scenario and discuss the potential consequences and implications for future policy. Realizing that conscientious objection may not be a viable option in a rural or remote context has implications for not only medical assistance in dying, but other ethically sensitive healthcare services as well. These considerations have implications for policy in other jurisdictions allowing or considering medically assisted deaths, as well as other rural and remote areas where nurses may face ethical dilemmas.

Comparison of attitude of nurses and nursing students toward euthanasia

BACKGROUND

Euthanasia is a controversial issue in many countries. However, there is little evidence about attitudes of nurses and nursing students toward euthanasia.

RESEARCH AIMS

The present study aimed to compare nurses and nursing students' attitudes toward euthanasia.

RESEARCH DESIGN

This is a descriptive cross-sectional study.

PARTICIPANTS AND RESEARCH CONTEXT

Using census sampling, 390 nurses and 125 nursing students were enrolled in this study.

METHODS

Data were collected using a socio-demographic questionnaire and Euthanasia Attitude Scale that included 20 items that sought to record participants' level of agreement with euthanasia based on a Likert-type scale.

ETHICAL CONSIDERATIONS

Objectives of the study were stated for all samples, and emphasized the confidentiality of their specifics and responses, and informed written consent was obtained from all participants.

FINDINGS

The mean score of nurses and nursing students' attitudes about euthanasia was 3.14 ± 0.26 and 3.22 ± 0.24 out of 5, respectively. The majority of nurses (n = 250, 65.78%) and nursing students (n = 97, 80.83%) had a positive attitude toward euthanasia. There was a significant statistical difference between the attitudes of nurses and nursing students to euthanasia (p = .005).

DISCUSSION

The results indicated that the majority of students and nurses had a positive attitude regarding euthanasia.

CONCLUSION

It was recommended to conduct more studies on euthanasia in Iran.

Ethical challenges in home-based care: A systematic literature review

Because of the transfer of responsibility from hospitals to community-based settings, providers in home-based care have more responsibilities and a wider range of tasks and responsibilities than before, often with limited resources. The increased responsibilities and the complexity of tasks and patient groups may lead to several ethical challenges. A systematic search in the databases MEDLINE, CINAHL, and SveMed+ was carried out in February 2019 and August 2020. The research question was translated into a modified PICO (Population, Intervention, Comparison, and Outcome) worksheet. A total of 40 articles were included. The review is conducted according to the Vancouver Protocol. The main findings from the systematic literature review show that ethical challenges experienced by healthcare and social care providers in home-based care are related to autonomy and balancing ethical principles, decisions regarding intensity of care, challenges related to priority settings, truth-telling, and balancing the professional role. Findings regarding ethical challenges within home-based care are in line with findings from institutional healthcare and social care settings. However, some significant differences from the institutional context are also highlighted.

Riding an elephant: A qualitative study of nurses' moral journeys in the context of Medical Assistance in Dying (MAiD)

AIMS AND OBJECTIVES

To describes nurses' moral experiences with Medical Assistance in Dying in the Canadian context.

BACKGROUND

Nurses perform important roles in Medical Assistance in Dying in Canada and do so within a unique context in which Medical Assistance in Dying is provided through healthcare services and where accessibility is an important principle. International literature indicates that participating in Medical Assistance in Dying can be deeply impactful for nurses and requires a high degree of moral sense-making.

DESIGN

A qualitative interview study guided by Interpretive Description using the COREQ checklist.

RESULTS

Fifty-nine nurses from across Canada participated in the study. The decision to participate in Medical Assistance in Dying was influenced by family and community, professional experience and nurses' proximity to the act of Medical Assistance in Dying. Nurses described a range of deep and sometimes conflicting emotional reactions provoked by Medical Assistance in Dying. Nurses used a number of moral waypoints to make sense of their decision including patient choice, control and certainty; an understanding that it was not about the nurse; a commitment to staying with patients through suffering; consideration of moral consistency; issues related to the afterlife; and the peace and gratitude demonstrated by patients and families.

DISCUSSION

The depth of nurses' intuitional moral responses and their need to make sense of these responses are consistent with Haidt's theory of moral experience in which individuals use reasoning primarily to explain their moral intuition and in which moral change occurs primarily through compassionate social interaction. Further, work on the moral identity of nursing provides robust explanation of how nurses' moral decisions are contextually and relationally mediated and how they seek to guard patient vulnerability, even at their own emotional cost.

CONCLUSION

Medical Assistance in Dying is impactful for nurses, and for some, it requires intensive and ongoing moral sense-making.

RELEVANCE TO CLINICAL PRACTICE

There is a need to provide support for nurses' moral deliberation and emotional well-being in the context of Medical Assistance in Dying care.

Constructing Good Nursing Practice for Medical Assistance in Dying in Canada: An Interpretive Descriptive Study

Nurses play a central role in Medical Assistance in Dying (MAiD) in Canada. However, we know little about nurses' experiences with this new end-of-life option. The purpose of this study was to explore how nurses construct good nursing practice in the context of MAiD. This was a qualitative interview study using Interpretive Description. Fifty-nine nurses participated in semi-structured telephone interviews. Data were analyzed inductively. The findings illustrated the ways in which nurses constructed artful practice to humanize what was otherwise a medicalized event. Registered nurses and nurse practitioners described creating a person-centered MAiD process that included establishing relationship, planning meticulously, orchestrating the MAiD death, and supporting the family. Nurses in this study illustrated how a nursing gaze focused on relationality crosses the moral divides that characterize MAiD. These findings provide an in-depth look at what constitutes good nursing practice in MAiD that can support the development of best practices.