Becoming a medical assistance in dying (MAiD) provider: an exploration of the conditions that produce conscientious participation

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.

The Evolving Complexities of MAID Care in Canada From a Nursing Perspective

Medical Assistance in Dying (MAID) legislation has evolved rapidly in Canada with significant impacts on nursing practice. The purpose of this paper is to describe evolving complexities in legislative context and practice standards that influence the experiences nurse practitioners and registered nurses have with MAID. Qualitative interviews were conducted with 25 registered nurses and 10 nurse practitioners from diverse contexts across Canada. Participants described their practices and considerations when discussing MAID as part of advance care planning; their use of, and challenges with, waivers of consent; their practice considerations in negotiating the complexities of clients for whom death is not reasonably foreseeable; and their moral wrestling with the inclusion of MAID for persons whose sole underlying medical condition is mental illness. Findings illustrate the moral complexities inherent in the evolving legislation and the importance of robust health and social care systems to the legal and ethical implementation of MAID in Canada.

Practitioners' experiences with 2021 amendments to Canada's medical assistance in dying law: a qualitative analysis

Background

In 2016, Canada joined the growing number of jurisdictions to legalize medical assistance in dying (MAiD), when the Supreme Court of Canada's decision in Carter v Canada took effect and the Canadian Parliament passed Bill C-14. Five years later, Bill C-7 introduced several significant amendments. These included removing the 'reasonably foreseeable natural death' requirement (an aspect that was widely debated) and introducing the final consent waiver. Since Bill C-7 is so new, very little research has investigated its operation in practice.

Objectives

This study investigates the experiences of MAiD assessors and providers regarding the Bill C-7 amendments. It explores implications for understanding and improving regulatory reform and implementation.

Design

Qualitative thematic analysis of semi-structured interviews.

Methods

In all, 32 MAiD assessors and providers (25 physicians and 7 nurse practitioners) from British Columbia (n = 10), Ontario (n = 15) and Nova Scotia (n = 7) were interviewed.

Results

The analysis resulted in five themes: (1) removing barriers to MAiD access; (2) navigating regulatory and systems recalibration; (3) recognizing workload burdens; (4) determining individual ethical boundaries of practice and (5) grappling with ethical tensions arising from broader health system challenges.

Conclusion

This is one of the first studies to investigate physicians' and nurse practitioners' experiences of the impact of Bill C-7 after the legislation was passed. Bill C-7 addressed key problems under Bill C-14, including the two witnesses requirement and the 10-day waiting period. However, it also introduced new complexities as practitioners decided how to approach cases involving a non-reasonably foreseeable natural death (and contemplated the advent of MAiD for persons with a mental disorder as a sole underlying condition). This study highlights the importance of involving practitioners in advance of legislative changes. It also emphasizes how the regulation of MAiD involves a range of organizations, which requires strong leadership and coordination from the government.

A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change

BACKGROUND

In June 2016, Canada legalized medical assistance in dying (MAiD). From the outset, some healthcare institutions (including faith-based and non-faith-based hospitals, hospices, and residential aged care facilities) have refused to allow aspects of MAiD onsite, resulting in patient transfers for MAiD assessments and provision. There have been media reports highlighting the negative consequences of these "institutional objections", however, very little research has examined their nature and impact.

METHODS

This study reports on findings from 48 semi-structured qualitative interviews conducted with MAiD assessors and providers, MAiD team members (working to coordinate care and lead MAiD programs in institutions and health authorities), and family caregivers on their experiences with institutional objection. Participants were recruited from the Canadian provinces of British Columbia, Ontario, and Nova Scotia. Data were analyzed using inductive thematic analysis.

RESULTS

Themes identified were: (1) basis for institutional objection (with objections commonly rooted in religious values and a particular philosophy of palliative care); (2) scope of objection (demonstrating a wide range of practices objected to); (3) lack of transparency regarding institutional position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for change. Participants reported that many institutions' objections had softened over time, lessening barriers to MAiD access and adverse impacts on patients and health practitioners. Participants attributed this positive change to a range of catalysts including advocacy by health practitioners and family members, policymaking by local health authorities, education, and relationship building. Nevertheless, some institutions, particularly faith-based ones, retained strong objections to MAiD, resulting in forced transfers and negative emotional and psychological impacts on patients, family members, and health practitioners.

CONCLUSIONS

This paper adds to the limited evidence base about the impacts of institutional objection and can inform practical and regulatory solutions in Canada and abroad. Reform is needed to minimize the negative impacts on patients, their caregivers, and health practitioners involved in MAiD practice.

Support structures for healthcare professionals involved in medical assistance in dying: Quebec, Canada, and the international landscape

When the Act Respecting End-of-Life Care came into effect in Quebec in 2015, nearly 30 Interdisciplinary Support Groups (ISGs) were formed to accompany practitioners and managers in the clinical, administrative, legal, and ethical practice of Medical Assistance in Dying (MAiD). Today, significant variability is observed in the constitution, role and functioning of ISGs. Based on an overview of national and international support structures, we highlight the strengths and challenges of ISGs. This article presents the results of the first phase of research conducted with 245 people involved in the practice of MAiD in Quebec. The objective is to survey current ISG practices in order to contrast them with those of equivalent structures in Canada and around the world. The intention is to guide leaders in the development of support structures for their institutions. In summary, ISGs are distinguished by their interdisciplinary constitution, their decentralized nature, and their proximity to the teams in the field. However, their service offer remains largely unknown to caregivers and the general population. This can be explained by the undefined and unlimited nature of their mandate, but also by the gap between the scope of their mandate and the lack of funding they receive.

Ethical Diversity and Practical Uncertainty: A Qualitative Interview Study of Clinicians' Experiences in the Implementation Period Prior to Voluntary Assisted Dying Becoming Available in their Hospital in Victoria, Australia

In the Australian state of Victoria, legislation allowing voluntary assisted dying (VAD) passed through parliament in November 2017. There was then an eighteen-month period before the start date for patient access to VAD, referred to as the "implementation period." The implementation period was intended to allow time for the relevant government department and affected organizations to develop processes before the Act came into effect in June 2019. This qualitative interview study investigates the perspectives of a multidisciplinary sample of twelve clinicians from a single metropolitan hospital during this implementation period. Maximum variation sampling was utilized to ensure breadth across discipline (medical, nursing, allied health), speciality, and stated level of support for the VAD legislation. Four key themes were identified from the interview data: preparing for the unknown, ethical diversity within the organization, building a respectful culture, and concerns about the inability of the legislated approach to capture clinical nuances. Overall, these clinicians' workplace experiences during the implementation period were shaped by the ethical diversity within their organization and a sense of uncertainty about how the VAD legislation would integrate with the practical realities of their clinical setting. The concept of "ethical diversity" could be a useful one for supporting staff in an organization during a VAD implementation period.

Leader as CARER: An ecological approach to designing a resilient MAiD program

In this paper, I use a personal narrative case study approach to describe how the evolution of the MAiD program at one Canadian hospital is informed by the model of a "care ecology," and how we designed our program to generate resilience and sustainability systemically and structurally, rather than relying on the self-care efforts of individuals. I will also reflect on the leader behaviours required to enable a care ecology, and how this challenges traditional approaches to leadership. This model may be adapted to other high-stress teams to promote longitudinal well-being for healthcare professionals and leaders, as well as quality care for patients and families.

Japan should initiate the discussion on voluntary assisted dying legislation now

BACKGROUND

No laws or official guidelines govern voluntary assisted dying (VAD) in Japan. A legislative bill on the termination of life-sustaining measures has yet to be sent to deliberations for legislation, due to strong opposition that has prevented it from being submitted to the Diet. However, Japan has recently witnessed several cases involving VAD.

MAIN TEXT

Against this backdrop, we argue that Japan should begin discussion on VAD legislation, referring to the Voluntary Assisted Dying Act 2017 (VADA2017), which was established in 2017 in Victoria, Australia. VADA2017 puts in place a wide range of stringent safeguards and is considered worldwide to be the safest and most conservative policy on a physician offering assisted dying based on the patient's premeditated request. We consider what opposing opinions from society would arise in response to the VADA2017. Among these will include arguments against VAD itself, those against the validation of this act, and opinions that oppose even the initiation of the dialogue on VAD.

CONCLUSIONS

We conclude that to protect the right to life among those placed in vulnerable positions and, at the same time, to respect decision-making of those who wish for immediate death due to unbearable suffering, the dialogue must immediately begin with that on introducing a policy more conservative than that of the VADA2017, which solidly considers arguments against VAD.

“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.

MAiD to Last: Creating a Care Ecology for Sustainable Medical Assistance in Dying Services

This paper depicts a case study of an organizational strategy for the promotion of ethical practice when introducing a new, high-risk, ethically-charged medical practice like Medical Assistance in Dying (MAiD). We describe the development of an interprofessional program that enables the delivery of high-quality, whole-person MAiD care that is values-based and sustainable. A “care ecology” strategy recognizes the interconnected web of relationships and structures necessary to support a quality experience of MAiD for patients, families, and clinicians. This program exemplifies a care ecology approach that addresses common barriers to entry to MAiD practice, and also meets the needs of a variety of stakeholders through the creation of patient and family resources, team supports, standards of practice, professional development opportunities, organizational infrastructure, and community partnerships. We also describe how a thriving care ecology evolves to remain resilient, and to enable integration as the needs of the organization, team and program change over time. The design and development of this program may be adapted to other jurisdictions and organizations where MAiD is introduced, or where new patient populations become eligible for MAiD. This care ecology model may also be applicable to the creation of sustainable programs that provide other morally controversial or novel clinical services.

Introducing Medical Assistance in Dying in Canada: Lessons on Pragmatic Ethics and the Implementation of a Morally Contested Practice

Medical Assistance in Dying (MAiD) in Canada has had a tumultuous social and legal history. In the 6 years since assisted dying was decriminalized by the Canadian Parliament in June 2016, the introduction of this practice into the Canadian healthcare system has been fraught with ethical challenges, practical hurdles and grass-roots innovation. In 2021, MAiD accounted for approximately 3.3% of all Canadian deaths annually, and more patients are seeking MAiD year over year as this option becomes more widely know. Unfortunately, some patients who want MAiD are unable to access it in a timely manner because of a lack of willing MAiD providers. This introduction describes statistics about the uptake of MAiD in Canada and the challenges presented by Canadians’ rapid acceptance of this end of life care option. In this special edition of HEC Forum about the implementation of MAiD in Canada, authors depict a range of ethical challenges and strategies to address issues related to MAiD access and quality, organizational engagement, clinician recruitment and retention, and support for a morally diverse workforce. In each article, the authors reflect on the question: What are the practical ethics involved in introducing assisted dying into a new healthcare context, and how can ethicists and ethics resources collaborate with stakeholders to ensure the integration of ethical considerations as this practice continues to evolve?

Access Isn't Enough: Evaluating the Quality of a Hospital Medical Assistance in Dying Program

Following an initial study of the needs of healthcare providers (HCP) regarding the introduction of Medical Assistance in Dying (MAiD), and the subsequent development of an assisted dying program, this study sought to determine the efficacy and impact of MAiD services following the first two years of implementation. The first of three aims of this research was to understand if the needs, concerns and hopes of stakeholders related to patient requests for MAiD were addressed appropriately. Assessing how HCPs and families perceived the quality of MAiD services, and determining if the program successfully accommodated the diverse needs and perspectives of HCPs, rounded out this quality evaluation. This research implemented a mixed-methods design incorporative of an online survey with Likert scale and open-ended questions, as well as focus groups and interviews with staff and physicians, and interviews with MAiD-involved family members. There were 356 online surveys, as well as 39 participants in six focus groups with HCP, as well as fourteen interviews with MAiD-involved family members. Participants indicated that high-quality MAiD care could only be provided with enabling resources such as policies and guidelines to ensure safe, evidence-based, standardized care, as well as a specialized, trained MAiD team. Both focus group and survey data from HCPs suggest the infrastructure developed by the hospital was effective in delivering high-quality MAiD care that supports the diverse needs of various stakeholders. This study may serve as a model for evaluating the impact and quality of services when novel and ethically-contentious clinical practices are introduced to healthcare organizations.

Getting Beyond Pros and Cons: Results of a Stakeholder Needs Assessment on Physician Assisted Dying in the Hospital Setting

This study assessed the attitudes and needs of physicians and health professional staff at a tertiary care hospital in Canada regarding the introduction of physician assisted dying (PAD) during 2015–16. This research aimed to develop an understanding of the wishes, concerns and hopes of stakeholders related to handling requests for PAD; to determine what supports/structures/resources health care professionals (HCP) require in order to ensure high quality and compassionate care for patients requesting PAD, and a supportive environment for all healthcare providers across the moral spectrum. This study constituted a mixed methods design with a qualitative descriptive approach for the study’s qualitative component. A total of 303 HCPs working in a tertiary care hospital completed an online survey and 64 HCPs working in hospital units with high mortality rates participated in 8 focus group discussions. Both focus group and survey data coalesced around several themes to support the implementation of PAD following the decriminalization of this practice: the importance of high quality care; honoring moral diversity; supporting values (such as autonomy, privacy, beneficence); and developing resources, including collaboration with palliative care, education, policies and a specialized team. This study provided the foundational evidence to support the development of the PAD program described in other papers in this collection, and can be a model for gathering evidence from stakeholders to inform the implementation of PAD in any healthcare organization.

Health care providers’ ethical perspectives on waiver of final consent for Medical Assistance in Dying (MAiD): a qualitative study

Background

With the enactment of Bill C-7 in Canada in March 2021, people who are eligible for medical assistance in dying (MAiD), whose death is reasonably foreseeable and are at risk of losing decision-making capacity, may enter into a written agreement with their healthcare provider to waive the final consent requirement at the time of provision. This study explored healthcare providers’ perspectives on honouring eligible patients’ request for MAiD in the absence of a contemporaneous consent following their loss of decision-making capacity.

Method

A critical qualitative methodology, using a feminist ethics theoretical lens with its focus on power and relationality, was used to examine how socio-political and environmental contexts influenced healthcare providers' moral agency and perspectives. Semi-structured interviews were conducted with 30 healthcare providers (13 physicians, six nurse practitioners, nine nurses and two social workers) from across Canada who provide MAiD-related care.

Results

Themes identified include; (1) balancing personal values and professional responsibilities, (2) anticipating strengths and limitations of the proposed waiver of final consent amendment, (3) experiencing ethical influences on decisions to enter into written agreements with eligible patients, (4) recognizing barriers to the enactment of MAiD in the absence of a contemporaneous consent and (5) navigating the potential for increased risks and burden.

Discussion

To our knowledge, this is the first study in Canada to explore healthcare providers’ perspectives on waiving the final consent for MAiD using a written agreement. Most participants supported expanding eligible people’s access to MAiD following loss of capacity, as they believed it would improve the patients’ comfort and minimize suffering. However, the lack of patients’ input at the time of provision and related ethical and legal challenges may impact healthcare providers’ moral agency and reduce some patients’ access to MAiD. Providers indicated they would enter into written agreements to waive final consent for MAiD on a case-by-case basis. This study highlights the importance of organizational, legal and professional support, adequate resources, clear policies and guidelines for the safety and wellbeing of healthcare providers and to ensure equitable access to MAiD.

Exploring key stakeholders' attitudes and opinions on medical assistance in dying and palliative care in Canada: a qualitative study protocol

INTRODUCTION

Canadians have had legal access to medical assistance in dying (MAiD) since 2016. However, despite substantial overlap in populations who request MAiD and who require palliative care (PC) services, policies and recommended practices regarding the optimal relationship between MAiD and PC services are not well developed. Multiple models are possible, including autonomous delivery of these services and formal or informal coordination, collaboration or integration. However, it is not clear which of these approaches are most appropriate, feasible or acceptable in different Canadian health settings in the context of the COVID-19 pandemic and in the post-pandemic period. The aim of this qualitative study is to understand the attitudes and opinions of key stakeholders from the government, health system, patient groups and academia in Canada regarding the optimal relationship between MAiD and PC services.

METHODS AND ANALYSIS

A qualitative, purposeful sampling approach will elicit stakeholder feedback of 25-30 participants using semistructured interviews. Stakeholders with expertise and engagement in MAiD or PC who hold leadership positions in their respective organisations across Canada will be invited to provide their perspectives on the relationship between MAiD and PC; capacity-building needs; policy development opportunities; and the impact of the COVID-19 pandemic on the relationship between MAiD and PC services. Transcripts will be analysed using content analysis. A framework for integrated health services will be used to assess the impact of integrating services on multiple levels.

ETHICS AND DISSEMINATION

This study has received ethical approval from the University Health Network Research Ethics Board (No 19-5518; Toronto, Canada). All participants will be required to provide informed electronic consent before a qualitative interview is scheduled, and to provide verbal consent prior to the start of the qualitative interview. Findings from this study could inform healthcare policy, the delivery of MAiD and PC, and enhance the understanding of the multilevel factors relevant for the delivery of these services. Findings will be disseminated in conferences and peer-reviewed publications.

"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.

Regulating voluntary assisted dying practice: A policy analysis from Victoria, Australia

BACKGROUND

Victoria is the first state in Australia to legalise voluntary assisted dying (elsewhere known as physician-assisted suicide and euthanasia). The Victorian law took effect in 2019 after an 18-month implementation period designed to facilitate policy development and other regulatory infrastructure.

OBJECTIVE

To study publicly available policy documents regarding voluntary assisted dying in Victoria and the issues they seek to regulate.

METHODS

Policies were identified using a combination of search strategies to capture documents aimed at a broad range of stakeholders including health practitioners, patients, and families. The policies were thematically analysed using the Framework Method.

RESULTS

The study identified 60 policies and five themes: 1) conceptions of policy purpose; 2) degree of support for VAD; 3) guidance about process; 4) navigating conscientious objection; and 5) conceptualising voluntary assisted dying and its relationship with other aspects of end-of-life care. Outside of the detailed Victorian Government policies, there was little practical guidance for voluntary assisted dying provision. Instead, the non-governmental policies tended to focus on positioning regarding VAD and entry into the process.

CONCLUSION

The study demonstrates the value of a planned implementation period for jurisdictions contemplating voluntary assisted dying reform and highlights the challenges in policymaking for a practice that is contentious for some.

"What Is Right for Me, Is Not Necessarily Right for You": The Endogenous Factors Influencing Nonparticipation in Medical Assistance in Dying

Access to medical assistance in dying (MAID) is influenced by legislation, health care providers (HCPs), the number of patient requests, and the patients' locations. This research explored the factors that influenced HCPs' nonparticipation in formal MAID processes and their needs to support this emerging practice area. Using an interpretive description methodology, we interviewed 17 physicians and 18 nurse practitioners who identified as non-participators in formal MAID processes. Nonparticipation was influenced by their (a) previous personal and professional experiences, (b) comfort with death, (c) conceptualization of duty, (d) preferred end-of-life care approaches, (e) faith or spirituality beliefs, (f) self-accountability, (g) consideration of emotional labor, and (h) future emotional impact. They identified a need for clear care pathways and safe passage. Two separate yet overlapping concepts were identified, conscientious objection to and nonparticipation in MAID, and we discussed options to support the social contract of care between HCPs and patients.

Conscientious participants and the ethical dimensions of physician support for legalised voluntary assisted dying

The Australian state of Victoria legalised voluntary assisted dying (VAD) in June 2019. Like most jurisdictions with legalised VAD, the Victorian law constructs physicians as the only legal providers of VAD. Physicians with conscientious objection to VAD are not compelled to participate in the practice, requiring colleagues who are willing to participate to transact the process for eligible applicants. Physicians who provide VAD because of their active, moral and purposeful support for the law are known as conscientious participants. Conscientious participation has received scant attention in the bioethics literature. Patient access to VAD is contingent on the development of a sufficient corpus of conscientious participants in permissive jurisdictions. This article reports the findings of a small empirical study into how some Victorian physicians with no in-principle opposition towards the legalisation of VAD, are ethically orientating themselves towards the law, in the first 8 months of the law's operation. It finds that in-principle-supportive physicians employ bioethical principles to justify their position but struggle to reconcile that approach with the broader medical profession's opposition. This study is part of the first tranche of empirical research emerging from Australia since the legalisation of VAD in that country for the first time in over 20 years.