Provision of medical assistance in dying: a scoping review

The debate rages on: physician-assisted suicide in an ethical light

The British Medical Association and some Royal Colleges have recently changed their stance on physician-assisted suicide from 'opposed' to forms of 'neutral'. The Royal College of Anaesthetists will poll members soon on whether to follow suit. Elsewhere neutrality amongst professional bodies has preceded legalisation of physician-assisted suicide. We examine the arguments relevant to the anaesthesia community and its potential impact in the UK.

Should Physician-Assisted Suicide or Euthanasia be Legalized in the United States? A Medically Informed Perspective

There is a pressing debate in the United States concerning the implied physicians' obligation to do no harm and the status of legalizing physician-assisted suicide (PAS). Key issues that underpin the debate are important to consider. These include: (1) foundational medical beginnings; (2) euthanasia's historical and legal background context; and (3) the key arguments held by those for and against legalization of PAS. This paper reviews the major claims made by proponents for the legalization of PAS and the associated complexities and concerns that help underscore the importance of conscience freedoms. Relief of suffering, respect for patient autonomy, and public policy arguments are discussed in these contexts. We argue here that the emphasis by healthcare providers should be on high quality and compassionate care for those at the end of life's journey who are questioning whether to prematurely end their lives. If medicine loses its chief focus on the quality of caring-even when a cure is not possible-it betrays its objective and purpose. In this backdrop, legalization of PAS harms not only healthcare professionals, but also the medical profession's mission itself. Medicine's foundation is grounded in the concept of never intentionally to inflict harm. Inflicting death by any means is not professional or proper, and is not trustworthy medicine.

The Physician-Assisted Suicide Pathway in Italy: Ethical Assessment and Safeguard Approaches

Although in Italy there is currently no effective law on physician-assisted suicide or euthanasia, Decision No. 242 issued by the Italian Constitutional Court on September 25, 2019 established that an individual who, under specific circumstances, has facilitated the implementation of an independent and freely-formed resolve to commit suicide by another individual is exempt from criminal liability. Following this ruling, some citizens have submitted requests for assisted suicide to the public health system, generating a situation of great uncertainty in the application processes. As a matter of fact, shared and defined procedures are lacking as Decision 242/2019 merely added some principles on which the legislature will have to base its future intervention. This paper analyses the advisory role that the Decision attributes to territorial ethics committees with the aim of stimulating discussions on their role in oversight mechanisms. The proposed conclusion is that the envisaged role does not appear consistent with the functions of these bodies and is ultimately substantially undefined and unjustified.

Barriers and facilitators for engaging in the practice of medical assistance in dying among providers in Canada: a scoping review protocol

OBJECTIVE

This review will explore the perceived barriers and facilitators for engaging in the practice of medical assistance in dying (MAiD) from the perspective of physicians, nurse practitioners, and medical residents in Canada.

INTRODUCTION

The number of MAiD requests in Canada is growing steadily and is predicted to continue to grow with the passing of Bill C-7 in 2021, which expands access to individuals whose deaths are not reasonably foreseeable. Under federal law, physicians and nurse practitioners are the only health care professionals permitted to assess for and administer MAiD. Providers are not obligated to engage in the practice of MAiD; therefore, patient access relies on providers' readiness to engage in the practice. More information is needed to understand the barriers and facilitators for engaging in MAiD care from the perspective of providers.

INCLUSION CRITERIA

This review will consider studies that identify physicians, nurse practitioners, and medical residents' perceived barriers and facilitators for engaging in the practice of MAiD in Canada. Physicians, nurse practitioners, and medical residents who do not directly administer MAiD, including those who identify as conscientious objectors or non-participants, will be included. Studies looking at barriers and facilitators for providing MAiD care to individuals with dementia, mental illness, or for individuals under the age of 18 years will be excluded.

METHODS

MEDLINE, Embase, CINAHL with Full-text, and APA PsycINFO will be searched. Studies will be screened and data extracted by 2 independent reviewers using a tool created for this review. The scoping review findings will be presented in a narrative format and mapped in tables to address the review aims.

MAiD as human connection: Stories and metaphors of physician providers' existential lived experience

Being the one who provides an assisted death is complex and profound, and yet the lived experience of this novel act is little understood in Canada. In this article, we highlight the methodological issue of how one might peer behind emergent threads that addressed us in the data. A narrative-hermeneutic approach revealed that for the eight providers we interviewed, this is an embodied existential experience. The act of providing MAiD fostered embodied feelings of conviction, courage, compassion, and intimacy. We ultimately find that the experience of providing MAiD is human connection. The experience holds a dimension of the existential and provides a way to get closer to the unsayable profoundness that occurs in the space of providing death for a suffering other. This is important if not crucial in medicine and health care, as shared experiences connect us to what it is to be human, especially at end of life.

Liver transplantation with donation after medical assistance in dying: Case series and systematic review of the literature

Medical assistance in dying (MAiD) has been a legally approved practice in Canada since 2016. Only recently have patients undergoing MAiD also been considered as donors for liver transplantation (LT). This study aimed to evaluate a case series of LT outcomes for recipients with MAiD donors and was paired with a systematic literature review of studies assessing the efficacy of MAiD-associated liver donation. A retrospective chart review of patients registered within the LT Registry at London Health Sciences Centre (LHSC) in London, Ontario, Canada, that had received MAiD donor LT was conducted to develop a case series. Descriptive statistics were produced based on available patient outcomes information. The systematic review included euthanasia due to MAiD being a term exclusive to Canada. Case series had a 100% 1-year graft survival rate, with 50% of patients experiencing early allograft dysfunction but having no significant clinical outcome. A single case of postoperative biliary complication was reported. Median warm ischemic time ranged from 7.8-13 minutes among case series and literature reviews. Utilization of donation after circulatory death allografts procured after MAiD appears to be promising. Mechanisms associated with potential impact in postoperative outcomes include relatively lower warm ischemic time relative to donation after circulatory death Maastricht III graft recipients.

Assisted suicide a 20th century problem, Palliative care a 21st century solution

Assisted suicide and euthanasia are two forms of what is being called 'assisted dying', and they are touted by proponents as "progressive" and "compassionate". In fact, they are, on the contrary, relics from the last century: today, in the 21^st century, we have moved beyond such archaic solutions - we now have, instead, proper evidence-based palliative care. It is this that should be demanded for all. This article will dispel the myths around dying that are often cited. It will also explore the oft-overlooked tragedies generated by assisted suicide, in the hope you, the reader, can be better informed about this retrogressive practice.

Comparison of official reporting on assisted suicide and euthanasia across jurisdictions

OBJECTIVES

Official data reports from countries where assisted suicide and euthanasia is legal are an important resource for discerning participation rates, patient safety and transparency in the way that assisted dying is legal. We aimed to identify what information is published in official data reports on assisted suicide and euthanasia across jurisdictions.

METHODS

We searched for official data reports from every jurisdiction where assisted suicide or euthanasia is legal. Searches were conducted on these countries' official health authority websites as well as on mainstream search engines. The data measures included within each report were described in four categories: participation data, patient characteristics, clinician characteristics, and drugs and dying process.

RESULTS

We found that 16 jurisdictions where assisted suicide or euthanasia is currently legal regularly publish data reports regarding its practice. The information included within these official reports varies greatly, with few measures published across all or most jurisdictions.

CONCLUSIONS

Differences in the kinds of information published within official reports on assisted suicide and euthanasia makes comparing the practice of assisted suicide and euthanasia across jurisdictions challenging. Many jurisdictions fail to report data measures, which could be valuable to the understanding of assisted suicide and euthanasia practices within that country. Improving data reporting across jurisdictions where assisted suicide and euthanasia is legal, for example, through establishing minimum requirements for data collection and reporting, is an important step towards ensuring patient safety and the transparent practice of assisted suicide and euthanasia.

Qualities of the dying experience of persons who access medical assistance in dying: A scoping review

Defining a "good death" is complex and grounded in diverse cultural, social, and personal factors. Although there is a significant body of literature exploring the broad concepts of death and dying, there is a dearth in literature that has explored what constitutes a good death for persons undergoing assisted dying such as Medical Assistance in Dying (MAiD). In this scoping review of 19 articles, we explore dying experiences and what a good death entails for people accessing MAiD. Understanding personal values and ideas about positive dying experiences can guide patients, care partners, and clinicians in their preparation toward, and facilitation of, a good death experience particularly among persons who access MAiD.

Attitudes of university hospital staff towards in-house assisted suicide

Objective

To investigate staff attitudes toward assisted suicide in the hospital setting in Switzerland.

Design

Cross-sectional study.

Setting

Two University Hospitals in French speaking regions of Switzerland.

Participants

13’834 health care professionals, including all personnel caring for patients, were invited to participate.

Main outcome measures and other variables

Attitudes towards the participation of hospital health care professionals in assisted suicide were investigated with an online questionnaire.

Results

Among all invited professionals, 5’127 responded by filling in the survey at least partially (response rate 37.0%), and 3’683 completed the entire survey (26.6%). 73.0% of participants approved that this practice should be authorized in their hospital and saw more positive than negative effects. 57.6% would consider assisted suicide for themselves. Non-medical professionals were 1.28 to 5.25 times more likely to approve assisted suicide than physicians (p<0.001). 70.7% of respondents indicated that each professional should have the choice of whether to assist in suicide.

Conclusions

This multiprofessional survey sheds light on hospital staff perceptions of assisted suicide happening within hospital walls, which may inform the development of rules considering their wishes but also their reluctances. Further research using a mixed-methods approach could help reach an in-depth understanding of staff’s attitudes and considerations towards assisted suicide practices.

Efficacy and safety of drugs used for 'assisted dying'

BACKGROUND

'Assisted dying' is practiced in some European countries and US states. Legislation suggests that there exists an easily prescribed drug which consistently brings about death quickly and painlessly. Evidence from jurisdictions where 'assisted dying' is practiced, however, reveals that hastening patient death is not so simple.

SOURCES OF DATA

This report is a collation of assisted suicide and euthanasia drug protocols published by the Canadian Association of MAiD Assessors and Providers and the Royal Dutch Medical Association, annual data reports from the USA and Canada and relevant academic publications pertaining to methods of 'assisted dying' in the USA, Belgium, Canada and Switzerland.

AREAS OF AGREEMENT

A wide variety of lethal drug combinations are used for people who want their life ended, and the prevalence of complications and failures in intentionally ending life suggest that 'assisted dying' applicants are at risk of distressing deaths.

AREAS OF CONTROVERSY

The efficacy and safety of 'assisted dying' drugs are currently difficult to assess, as clinician reporting is often very low.

GROWING POINTS

The findings from this report reveal that little attention has been given to the problem of unmonitored prescribing and administering of lethal drug combinations, whose mode of action is unclear.

AREAS TIMELY FOR DEVELOPING RESEARCH

In order to properly assess the efficacy and safety of 'assisted dying', a more thorough means of data collection regarding the drugs used must be implemented and research is urgently needed into their mode of action.

Medications and dosages used in medical assistance in dying: a cross-sectional study

BACKGROUND

There is little evidence describing the technical aspects of medical assistance in dying (MAiD) in Canada, such as medications, dosages and complications. Our objective was to describe clinical practice in providing MAiD in Ontario and Vancouver, Canada, and explore relations between medications used, time until death and complications.

METHODS

We conducted a retrospective cohort study of a sample of adult (age ≥ 18 yr) patients who received MAiD in Ontario between 2016 and 2018, and patients who received MAiD in 1 of 3 Canadian academic hospitals (in Hamilton and Ottawa, Ontario, and Vancouver, British Colombia) between 2019 and 2020. We used de-identified data for 2016-2018 from the Office of the Chief Coroner for Ontario MAiD Database and chart review data for 2019-2020 from the 3 centres. We used multivariable parametric survival analysis to identify relations between medications, dosages and time from procedure start until death.

RESULTS

The sample included 3557 patients (1786 men [50.2%] and 1770 women [49.8%] with a mean age of 74 [standard deviation 13] yr). The majority of patients (2519 [70.8%]) had a diagnosis of cancer. The medications most often used were propofol (3504 cases [98.5%]), midazolam (3251 [91.4%]) and rocuronium (3228 [90.8%]). The median time from the first injection until death was 9 (interquartile range 6) minutes. Standard-dose lidocaine (40-60 mg) and high-dose propofol (> 1000 mg) were associated with prolonged time until death (prolonged by a median of 1 min and 3 min, respectively). Complications occurred in 41 cases (1.2%), mostly related to venous access or need for administration of a second medication.

INTERPRETATION

In a large sample of patients who died with medical assistance, certain medications were associated with small differences in time from injection to death, and complications were rare. More research is needed to identify the medication protocols that predict outcomes consistent with patient and family expectations for a medically assisted death.

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

Background:

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

Objective:

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

Design:

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

Participants:

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

Results:

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

Limitations:

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

Conclusion:

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

Hospital Pharmacists' Experiences with Medical Assistance in Dying: A Qualitative Study

Background

Pharmacists in many countries have long been involved in some aspect of assisted dying. Since 2016, when Canada enacted legislation permitting medical assistance in dying (MAiD), the number of patients seeking the procedure has increased yearly. Despite the global nature of pharmacists' involvement, little is known about how they experience MAiD practice.

Objective

To study how pharmacists experience the practice of caring for patients who seek MAiD.

Methods

This qualitative study used semistructured interviews with pharmacists who had cared for patients seeking MAiD. Interviews, conducted between June 2019 and October 2020, were audio-recorded and transcribed verbatim. Data were examined using a modified framework analysis approach. Data were coded and sorted using Quirkos and Microsoft Excel software. Themes were defined through an iterative process involving constant comparison.

Results

Nineteen hospital pharmacists representing a range of practice settings in Alberta participated in the study. The experience of caring for patients seeking assistance in dying brought to light 3 themes: finding a place in the process, serving in a caring role, and bearing emotional burdens. Pharmacists' experiences were personal, relational, emotional, and dynamic.

Conclusions

Each of the pharmacists experienced MAiD practice in a unique way. Although their roles in MAiD were primarily medication-focused, their experiences highlighted the centrality of patient choices, autonomy, and needs. The results of this study will inform pharmacists (including those not yet engaged in MAiD practice) about the role, and will also be valuable for pharmacy organizations and educators seeking to support pharmacists and the profession, as well as policy-makers seeking to expand pharmacists' roles in MAiD.

How can we improve the experiences of patients and families who request medical assistance in dying? A multi-centre qualitative study

Background

Medical assistance in dying has been available in Canada for 5 years, but it is unclear which practices contribute to high-quality care. We aimed to describe patient and family perspectives of quality of care for medical assistance in dying.

Methods

We conducted a multi-centre, qualitative descriptive study, including face to face or virtual one-hour interviews using a semi-structured guide. We interviewed 21 english-speaking patients found eligible for medical assistance in dying and 17 family members at four sites in Canada, between November 2017 and September 2019. Interviews were de-identified, and analyzed in an iterative process of thematic analysis.

Results

We identified 18 themes. Sixteen themes were related to a single step in the process of medical assistance in dying (MAID requests, MAID assessments, preparation for dying, death and aftercare). Two themes (coordination and patient-centred care) were theme consistently across multiple steps in the MAID process. From these themes, alongside participant recommendations, we developed clinical practice suggestions which can guide care.

Conclusions

Patients and families identified process-specific successes and challenges during the process of medical assistance in dying. Most importantly, they identified the need for care coordination and a patient-centred approach as central to high-quality care. More research is required to characterize which aspects of care most influence patient and family satisfaction.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12904-021-00882-4.

Because it was new: Unexpected experiences of physician providers during Canada's early years of legal medical assistance in dying

Implementing newly legalized euthanasia or assisted dying presents challenges. The procedure is high-stakes and irreversible and the context is controversial and associated with high emotions and strong opinions. This qualitative study reports unexpected experiences of twenty-one medical doctors who provided Medical Assistance in Dying (MAID) in the first years after legalization in Canada. The phrase 'because it was new' occurred multiple times as doctors attributed unanticipated experiences to the lack of individual and collective experience or knowledge. Positively viewed surprises included increased awareness of palliative care and an unexpected personal sense of fulfillment from helping others. Negative surprises were attributed multiple factors including ambiguously phrased legislation, systems issues and individual inexperience. Participants described issues such as technical difficulties around provision, provider anxiety, logistical snags and inability to adequately counsel and guide families. Participants expressed desire for more guidance, mentoring, training, and team communication. This article draws on phenomenological analysis of data to present providers' accounts of their experiences in the Canadian context. This will assist new providers and jurisdictions in anticipating and preparing for circumstances that were unexpected for the first cohort.

How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study

OBJECTIVES

The aims of this study are: (1) to create a flowchart process model of how medical assistance in dying (MAID) occurs in Nova Scotia (NS), Canada and (2) to detail how NS healthcare professionals are involved in each stage of MAID. The research questions are: how is the MAID process carried out and which professionals are involved at which points? and which roles and activities do professionals carry out during MAID?

DESIGN

Qualitative process model flowchart study with semistructured interviews.

SETTING

Primary and secondary care in NS, Canada.

PARTICIPANTS

Thirty-two interviewees self-selected to participate (12 physicians, 3 nurse practitioners (NP), 6 nurses, 6 pharmacists and 5 healthcare administrators and advocates). Participants were included if they conduct assessments, provide MAID, fill prescriptions, insert the intravenous lines, organise care and so on.

RESULTS

The flowchart process model details five stages of how MAID occurs in NS: (1) starting the MAID process, (2) MAID assessments, (3) MAID preparation (hospital in-patient, hospital outpatient, non-hospital), (4) day of MAID and (5) post-MAID (hospital in-patient and outpatient, non-hospital, after leaving setting). Nineteen points where the process could stop or be delayed were identified. MAID differs slightly by location and multiple professionals from different organisations are involved at different points. Some physicians and NP provide MAID for free as they cannot be reimbursed or find it too difficult to be reimbursed.

CONCLUSIONS

Our study adds knowledge about the MAID activities and roles of NS professionals, which are not documented in the international literature. Clinicians and pharmacists spend significant additional time to participate, raising questions about MAID's sustainability and uncompensated costs. The process model flowchart identifies where MAID can stop or be delayed, signalling where resources, training and relationship-building may need to occur. Knowing where potential delays can occur can help clinicians, administrators and policymakers in other jurisdictions improve MAID.