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

Statements of Austrian hospices and palliative care units after the implementation of the law on assisted suicide : A qualitative study of web-based publications

BACKGROUND

Since January 2022, assisted suicide (AS) in Austria is legal under certain conditions. One of these conditions is informative consultations with two physicians, one of whom must be qualified in palliative medicine. Patients who are thinking about AS can approach palliative care institutions. This study aims to assess the availability and nature of Austrian palliative care institutions' web-based statements about AS.

METHODS

In this qualitative study, the websites of all Austrian palliative care units (n = 43) and all Austrian inpatient hospices (n = 14) were searched for possible statements on AS once in February 2022 and once in August 2022 using the three search terms "suicide", "assisted", and "euthanasia". The findings were subsequently evaluated using thematic analysis and NVivo software.

RESULTS

Statements or texts that included positions on AS were found on the websites of 11 institutions (19%). The results covered three main themes 1) demarcation: denial of involvement and judgment about AS, 2) duty: handling of requests and describing the target group of care recipients, and 3) explanation: experience, values, concerns, and demands.

CONCLUSION

The results of this study indicate that people in Austria who wish to have AS and who may use the internet as their first source of information largely find no relevant information. There is no online statement of a palliative care or hospice institution that endorses AS. Positions on AS are mostly lacking, while reluctant attitudes of Christian institutions are predominant.

Does voluntary assisted dying impact quality palliative care? A retrospective mixed-method study

OBJECTIVES

We aimed to explore the relationship between the pursuit of voluntary assisted dying (VAD) and the delivery of quality palliative care in an Australian state where VAD was newly available METHODS: We adopted a retrospective convergent mixed-methods design to gather and interpret data from records of 141 patients who expressed an interest in and did or did not pursue VAD over 2 years. Findings were correlated against quality domains.

RESULTS

The mean patient age was 72.4 years, with the majority male, married/partnered, with a cancer diagnosis and identifying with no religion. One-third had depression, anxiety or such symptoms, half were in the deteriorating phase, two-thirds required help with self-care and 83.7% reported moderate/severe symptoms. Patients sought VAD because of a desire for autonomy (68.1%), actual suffering (57.4%), fear of future suffering (51.1%) and social concerns (22.0%). VAD enquiries impacted multiple quality domains, both enhancing or impeding whole person care, family caregiving and the palliative care team. Open communication promoted adherence to therapeutic options and whole person care and allowed for timely access to palliative care. Patients sought VAD over palliative care as a solution to suffering, with the withholding of information impacting relationships.

SIGNIFICANCE OF RESULTS

As legislation is expanded across jurisdictions, palliative care is challenged to accompany patients on their chosen path. Studies are necessary to explore how to ensure the quality of palliative care remains enhanced in those who pursue VAD and support continues for caregivers and staff in their accompaniment of patients.

Conscience-Based Barriers to Medical Aid in Dying: A Survey of Colorado Physicians

BACKGROUND

Approximately 20% of the United States' population lives in a state or jurisdiction where medical aid in dying (MAiD) is legal. It is unknown how physicians' own barriers are associated with their provision of the spectrum of MAiD services.

OBJECTIVE

To measure physicians' religious and/or ethical barriers to providing MAiD services and how such barriers relate to physicians' intentions and behaviors.

DESIGN

Three-wave cross-sectional survey fielded in Colorado in 2020-2021.

PARTICIPANTS

Physicians providing care to patients likely clinically eligible for MAiD according to probabilistic sampling.

MAIN MEASURES

Physicians self-reported barriers to their own participation in MAiD. We considered large ethical and/or religious barriers to be conscience-based barriers. We measured physicians' self-reported intention to participate and self-reported prior participation in MAiD since it was legalized in Colorado in 2017. We estimated differences in intention and behavior outcomes according to presence of conscience-based barriers, adjusting for physician gender, race/ethnicity, time in practice, and specialty.

KEY RESULTS

Among 300 respondents, 26% reported "large" ethical and/or religious barriers to their involvement in MAiD. Physicians with longer time in practice and those identifying as non-White were more likely to report conscience-based barriers to MAiD. Comparing physicians with and without conscience-based barriers to MAiD, we found no difference in ancillary participation (discussing, referring) but significant differences in direct participation (serving as consultant [5% vs. 31%] or attending [0% vs. 22%]).

CONCLUSIONS

Approximately one-quarter of physicians likely to care for MAiD-eligible patients in Colorado reported religious and/or ethical barriers to MAiD. Despite religious and/or ethical barriers, the vast majority of physicians were willing to discuss MAiD and/or refer patients seeking MAiD services. These data provide important empirical foundation for policy from hospitals and health systems as well as medical specialty groups with official positions on MAiD.

Assisted dying and medical practice: questions and considerations for healthcare organisations

OBJECTIVES

Most clinical teams and organisations have not openly or formally discussed how they would react if physician-assisted suicide were to be legalised. This paper aims to discuss some of the potential challenges of introducing 'assisted dying' into medical care and produces a table of questions and considerations in light of such evidence so as to promote necessary discussion.

METHODS

An analysis of recent quantitative and qualitative studies from jurisdictions where 'assisted dying' is practised was conducted, with particular attention paid to studies which focus on the impact of legalising 'assisted dying' on clinical care.

RESULTS

'Assisted dying' can have a significant impact on clinical practice by complicating patient care and increasing clinician workload, potentially causing stress on patient care.

CONCLUSIONS

If physician-assisted suicide was to be legalised as part of existing healthcare, there are many questions that healthcare organisations must consider. Such considerations are tabulated in order to encourage awareness and discussion on the topic.

Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years?

OPINION STATEMENT

In considering the impact of medically hastened death (MHD) on cancer care, a wide range of variables needs to be considered including demographic factors, diagnoses, local cultural factors, and the legislative frameworks in place. Here, we present a synthesis of recently available published literature and empirical data collected following legislative change to enable MHD in Victoria, Australia to explore in detail the potential impact of MHD on cancer care with a focus on patients/families and professional groups. Our findings reveal that for patients and families, both physical and existential distress frequently underlie MHD requests, with the latter less readily recognised by health professionals. The responses of those around the patient making the request may have a very significant impact on relationships within families and upon the nature of the subsequent bereavement. For palliative care, while differing views may remain, it appears that there has been some accommodation of MHD into or alongside practice over time. The recognition of a shared commitment to relief of suffering of palliative care and MHD appears a helpful means of establishing how these practices may co-exist. In cancer practice more broadly, as individual professionals reflect upon their own roles, new relationships and pathways of patient movement (or referral) must be established in response to patients' requests. Our findings also highlight many unanswered questions in understanding the impact of MHD, including that upon those dying who choose not to access MHD, First Nations peoples, the participating health professionals' longer term, and the relief of suffering itself. A systematic approach to the evaluation of MHD legislation must be adopted in order to understand its full impact. Only then could it be determined if the aspirations for such legislative change were being met.

Circumstances affecting patients' euthanasia or medically assisted suicide decisions from the perspectives of patients, relatives, and healthcare professionals: A qualitative systematic review

This study aims to explore circumstances affecting patients' euthanasia and medically assisted suicide (MAS) decisions from the perspectives of patients, relatives, and healthcare professionals. A qualitative systematic review was performed following PRISMA recommendations. The review protocol is registered in PROSPERO (CRD42022303034). Literature searches were conducted in MEDLINE, EMBASE, CINAHL Complete, Eric, PsycInfo, and citation pearl search in Scopus from 2012 to 2022. In total, 6840 publications were initially retrieved. The analysis included a descriptive numerical summary analysis and a qualitative thematic analysis of 27 publications, resulting in two main themes-Contexts and factors influencing actions and interactions, and Finding support while dealing with resistance in euthanasia and MAS decisions-and related sub-themes. The results illuminated the dynamics in (inter)actions between patients and involved parties that might both impede and facilitate patients' decisions related to euthanasia/MAS, potentially influencing patients' decision-making experiences, and the roles and experiences of involved parties.

Use of palliative sedation following Medical Assistance in Dying (MAiD) legislation: A mixed-methods study of palliative care providers

OBJECTIVES

Palliative sedation (PS) and Medical Assistance in Dying (MAiD) are options for end-of-life (EOL) care in Canada, since the latter was legalized in 2016. Little research to date has explored the potential impact of MAiD on PS practices. This study investigated physicians' perceptions of their practices surrounding PS and how they may have changed since 2016.

METHODS

A survey (n=37) and semi-structured interviews (n=23) were conducted with palliative care providers throughout Ontario. Questions focused on PS practices and explored potential changes following the implementation of MAiD. Codes were determined collaboratively and applied line-by-line by 2 independent investigators. Survey responses were analyzed alongside interview transcripts and noted to be concordant. Themes were generated via reflexive thematic analysis.

RESULTS

Thematic analysis yielded the following themes: (1) Increased patient/family knowledge of EOL care; (2) More frequent/fulsome discussions; (3) Normalization/repositioning of PS; and (4) Conflation and differentiation of PS/MAiD. Across these themes, participants espoused increased patient, family, and provider comfort with PS, which may stem equally from the advent of MAiD and the growth of palliative care in general. Participants also emphasized that, following MAiD, PS is viewed as a less radical intervention.

SIGNIFICANCE OF RESULTS

This is the first study to investigate physicians' perspectives on the impact of MAiD on PS. Participants strongly opposed treating MAiD and PS as direct equivalents, given the differences in intent and eligibility. Participants stressed that MAiD requests/inquiries should prompt individualized assessments exploring all avenues of symptom management - the results of which may or may not include PS.

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.

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.

Palliative Care and Physician Assisted Death

In the recent decade quite a few countries and regions legalised physician assisted death. While palliative care is already or becoming the standard end of life care in many countries, the increased availability of physician assisted death coupled with the secularisation of hospice in more settings require – where this has not happened yet – a clear response of palliative care specialists to patients’ requests for physician assisted death. The paper analyses the World Health Organisation’s current description of palliative care with a special focus on its prohibition of hastening death. Some palliative care professionals do not agree with the ban on hastening death, and these professionals’ non-conventional interpretation of palliative care actually seems to meet the wishes of some patients.

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.

Informal care-givers' attitudes towards medical assistance in dying for persons with dementia

Medical assistance in dying (MAID) is legal in Canada but cannot be accessed through an advance request. Some data suggest that informal care-givers of persons with dementia support the legalisation of advance requests for MAID. Opponents argue that care-givers' support is due to society's failure to address their well-documented burden and unmet needs. To our knowledge, this assumption has never been tested. To fill this knowledge gap, we conducted a survey among 204 Canadian informal care-givers of persons with dementia to (a) elicit their attitudes towards allowing no longer competent adults to access MAID through an advance request, and (b) test the hypothesis that attitudes are in part driven by the level of burden experienced by care-givers and unmet needs for support. Attitudes were elicited with a clinical vignette involving a woman with Alzheimer's disease who requests MAID while still competent, or through an advance request for the time after she would lose decisional capacity. Informal care-givers' support for MAID ranged from 60 per cent in the scenario where the person is still competent and likely has several more years to live, to 87 per cent when she is depicted as no longer competent, in severe distress and close to death. Quality-of-life considerations and the value of self-determination were key arguments in support of legalising advance requests for MAID. Using multivariable logistic regression, we found no evidence that burden and unmet support needs influence attitudes towards advance requests for MAID, after controlling for other determinants. These findings contribute new insights into people's attitudes towards the sensitive issue of whether MAID should be extended to persons with dementia-induced decisional incapacity.

Public interest in medical assistance in dying and palliative care

OBJECTIVES

Medical assistance in dying (MAiD) is legal in an increasing number of countries, but there are concerns that its availability may compromise access to palliative care. We assessed public interest in MAiD, palliative care, both, or neither, and examined characteristics associated with this interest.

METHODS

We surveyed a representative sample of the adult Canadian public, accessed through a panel from May to June 2019. Weighted generalised multinomial logistic regression analyses were used to determine characteristics associated with interest in referral to palliative care, MAiD, or both, in the event of diagnosis with a serious illness.

RESULTS

Of 1362 participants who had heard of palliative care, 611 (44.8% weighted (95% CI 42.1% to 47.5%)) would be interested in both MAiD and palliative care, 322 (23.9% (95% CI 21.5% to 26.2%)) palliative care alone, 171 (12.3% (95% CI 10.5% to 14.1%)) MAiD alone and 258 (19.0% (95% CI 16.9% to 21.2%)) neither. In weighted multinomial logistic regression analyses, interest in both MAiD and palliative care (compared with neither) was associated with better knowledge of the definition of palliative care, older age, female gender, higher education and less religiosity; interest in palliative care alone was associated with better knowledge of the definition of palliative care, older age, female gender and being married/common law; interest in MAiD alone was associated with less religiosity (all p<0.05).

CONCLUSIONS

There is substantial public interest in potential referral to both MAiD and palliative care. Simultaneous availability of palliative care should be ensured in jurisdictions where MAiD is legal, and education about palliative care should be a public health priority.

Emotional impact on healthcare providers involved in medical assistance in dying (MAiD): a systematic review and qualitative meta-synthesis

BACKGROUND

Medical assistance in dying (MAiD) traverses challenging and emotionally overwhelming territories: healthcare providers (HCPs) across jurisdictions experience myriad of affective responses secondary to possible tensions between normative and interwoven values, such as sanctity of life, dignity in death and dying and duty to care.

OBJECTIVE

To determine the emotional impact on HCPs involved in MAiD.

METHODS

Inclusion restricted to English language qualitative research studies from four databases (OVID Medline, EMBASE, CINAHL and Scopus), from beginning until 30 April 2021, and grey literature up to August 2021 were searched. Key author, citation and reference searches were undertaken. We excluded studies without rigorous qualitative research methodology. Included studies were critically appraised using the Joanna Briggs Institute's critical appraisal tool. Analysis was conducted using thematic meta-synthesis. The cumulative evidence was assessed for confidence using the Confidence in the Evidence from Reviews of Qualitative Research approach.

RESULTS

The search identified 4522 papers. Data from 35 studies (393 physicians, 169 nurses, 53 social workers, 22 allied healthcare professionals) employing diverse qualitative research methodologies from five countries were coded and analysed. The thematic meta-synthesis showed three descriptive emotional themes: (1) polarised emotions including moral distress (n=153), (2) reflective emotions with MAiD as a 'sense-making process' (n=251), and (3) professional value-driven emotions (n=352).

DISCUSSION

This research attempts to answer the question, 'what it means at an emotional level', for a MAiD practitioner. Legislation allowing MAiD for terminal illness only influences the emotional impact: MAiD practitioners under this essential criterion experience more polarised emotions, whereas those practising in jurisdictions with greater emphasis on allaying intolerable suffering experience more reflective emotions. MAiD practitioner's professional values and their degree of engagement influence the emotional impact, which may help structure future support networks. English language literature restriction and absence of subgroup analyses limit the generalisability of results.

Medical Aid in Dying: What Every Nurse Needs to Know

ABSTRACT

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

Physician-Assisted Suicide in Dementia: Paradoxes, Pitfalls and the Need for Prudence

There has been an increasing drive towards the legalization of physician-assisted suicide (PAS) in patients with dementia, particularly in patients with advanced disease and severe cognitive impairment. Advocacy for this position is often based on utilitarian philosophical principles, on appeals to the quality of life of the patient and their caregiver(s), or on economic constraints faced by caregivers as well as healthcare systems. In this paper, two lines of evidence against this position are presented. First, data on attitudes towards euthanasia for twenty-eight countries, obtained from the World Values Survey, is analyzed. An examination of this data shows that, paradoxically, positive attitudes towards this procedure are found in more economically advanced countries, and are strongly associated with specific cultural factors. Second, the literature on existing attitudes towards PAS in cases of dementia, along with ethical arguments for and against the practice, is reviewed and specific hazards for patients, caregivers and healthcare professionals are identified. On the basis of these findings, the author suggests that the practice of PAS in dementia is not one that can be widely or safely endorsed, on both cultural and ethical grounds. Instead, the medical field should work in collaboration with governmental, social welfare and patient advocacy services to ensure optimal physical, emotional and financial support to this group of patients and their caregivers.

Medical practitioners' views and experiences of being involved in assisted dying in Victoria, Australia: A qualitative interview study among participating doctors

RATIONALE

On June 19, 2019, Assisted Dying (AD) was legalized in the Australian state of Victoria, joining a small but growing cohort of jurisdictions internationally where AD is permitted. Few studies have examined perspectives of doctors who have participated in AD in jurisdictions where it has become legal, despite their pivotal role in the system.

OBJECTIVE

This study aimed to describe the beliefs, experiences and perspectives of doctors who had provided AD during the first 12 months of its operation in Victoria, Australia.

METHOD

In-depth, semi-structured interviews were conducted between April and July 2020 with 32 Victorian doctors who had been involved in the AD process during the first 12-months since it became legal in Victoria. The assumptions underpinning our methodology were guided by a phenomenological approach and reflexive thematic analysis was used to analyze the data.

RESULTS

Five major themes were identified: a nascent approach to care, practising within clinical and legal uncertainty, confronting practices, personal sacrifices and coping amid new challenges. A thematic schema was developed, illustrating that these themes were expressed as a balance of competing tensions of identity for doctors who provided AD for their patients in practice. A major tension was not just how doctors' perceptions impacted their own wellbeing and satisfaction, but also how these challenged their continued involvement in AD and, therefore, the system's overall ability to function.

CONCLUSION

Our findings show that while doctors discussed AD as an ethical practice, it also involved multiple identities with varying sources of meaning, and these identities were sometimes overlapping depending on context. As other jurisdictions increasingly move to legalize AD, a greater appreciation of the different role-based and group-based challenges involved in AD may improve AD implementation strategies.

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.

How does Medical Assistance in Dying affect end-of-life care planning discussions? Experiences of Canadian multidisciplinary palliative care providers

Background

More than a dozen countries have now legalized some form of assisted dying, and additional jurisdictions are considering similar legislations or expanding eligibility criteria. Despite the persistent controversies about the relationship between medicine, palliative care, and assisted dying, many people are interested in assisted dying. Understanding how end-of-life care discussions between patients and specialist palliative care providers may be affected by such legislation can inform end-of-life care delivery in the evolving socio-cultural and legal environment.

Aim

To explore how the Canadian Medical Assistance in Dying legislation affects end-of-life care discussions between patients and multidisciplinary specialist palliative care providers.

Design

Qualitative thematic analysis of semi-structured interviews.

Participants

Forty-eight specialist palliative care providers from Vancouver (n = 26) and Toronto (n = 22) were interviewed in person or by phone. Participants included physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health professionals (n = 4).

Results

Qualitative thematic analysis identified five notable considerations associated with Medical Assistance in Dying affecting end-of-life care discussions: (1) concerns over having proactive conversations about the desire to hasten death, (2) uncertainties regarding wish-to-die statements, (3) conversation complexities around procedural matters, (4) shifting discussions about suffering and quality of life, and (5) the need and challenges of promoting open-ended discussions.

Conclusion

Medical Assistance in Dying challenges end-of-life care discussions and requires education and support for all concerned to enable compassionate health professional communication. It remains essential to address psychosocial and existential suffering in medicine, but also to provide timely palliative care to ensure suffering is addressed before it is deemed irremediable. Hence, clarification is required regarding assisted dying as an intervention of last resort. Furthermore, professional and institutional guidance needs to better support palliative care providers in maintaining their holistic standard of care.

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

Background

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

Methods

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

Results

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

Conclusion

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