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Scheeres-Feitsma TM, Schaafsma P, van der Steen JT. A family affair: Repeated interviews with people with dementia and a euthanasia wish and their families. DEATH STUDIES 2024:1-11. [PMID: 39052438 DOI: 10.1080/07481187.2024.2376819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/27/2024]
Abstract
This study examines the reasons of people with dementia request euthanasia and how these reasons change over time with a special focus on reasons related to family. In addition, it examines how family relates to their loved one's euthanasia wish. Seven people with dementia and a euthanasia wish in the Netherlands were interviewed, and three years later, two of them and five family members were interviewed again. Four themes were identified using thematic analyses: (1) Protecting the relationship from the impact of dementia; (2) Private domain as the primary setting to discuss euthanasia; (3) Implicit expectation to respect and agree with the euthanasia wish; (4) Experienced responsibilities of family regarding the euthanasia wish. Professionals should be aware of the position of family and the interrelatedness of the person's concern for family happiness and families' moral commitment to agree and support the wish.
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Affiliation(s)
- Trijntje M Scheeres-Feitsma
- Protestant Theological University Amsterdam, Amsterdam, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Jenny T van der Steen
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
- Department of Primary and Community Care, Radboud university medical center, Nijmegen, The Netherlands
- Radboudumc Alzheimer Center, Nijmegen, The Netherlands
- Cicely Saunders Institute, King's College London, London, United Kingdom
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2
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Sperling D. Views, Attitudes and Challenges When Supporting a Family Member in Their Decision to Travel to Switzerland to Receive Aid-In-Dying. Int J Public Health 2024; 69:1607410. [PMID: 38978832 PMCID: PMC11228154 DOI: 10.3389/ijph.2024.1607410] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2024] [Accepted: 06/04/2024] [Indexed: 07/10/2024] Open
Abstract
Objectives Exploring the experiences, perceptions and meanings of family members and close friends of Israeli individuals who sought aid-in-dying outside Israel. Methods Using the phenomenological-interpretive approach, a qualitative research design was employed, based on ten in-depth semi-structured interviews with Israelis who had provided support for a relative who embarked on suicide tourism. Results The following five themes emerged from interviews: (1) facilitators for supporting an individual requesting suicide tourism; (2) choosing death and actively making the decision to die; (3) the meaning of traveling to die; (4) offering support throughout the process; and (5) facilitating procedures after death. Conclusion The participants spoke of the active role that they played in their relative's suicide-tourism journey. They conveyed conflicting emotions and values regarding the decision at hand, the ability to say goodbye thanks to their pre-planned death, helping to reduce their suffering and burden, and dealing with the challenge of disclosing the deceased's plans, before and after the act, as well as their own involvement in the process. Relatives of suicide-tourism patients should receive professional support during and following this difficult process.
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Navarrete J, Gray M, King MA, Mey A, Woods P, Schindel TJ. Medical assistance in dying: A reflection tool for pharmacists. Can Pharm J (Ott) 2024; 157:53-57. [PMID: 38463175 PMCID: PMC10924575 DOI: 10.1177/17151635241228215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Accepted: 11/06/2023] [Indexed: 03/12/2024]
Affiliation(s)
- Javiera Navarrete
- College of Health Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, University
of Alberta, Edmonton
- School of Public Health, University of Alberta, Edmonton
| | - Margaret Gray
- Edmonton and North Zones, Pharmacy Services, University of Alberta Hospital, Edmonton, Alberta
| | - Michelle A. King
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Australia
| | - Amary Mey
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Australia
- Griffith Institute for the Development of Education and Scholarship (Health IDEAS), Griffith University, Gold Coast, Australia
| | - Phillip Woods
- School of Pharmacy and Medical Sciences, Griffith University, Gold Coast, Australia
| | - Theresa J. Schindel
- College of Health Sciences, Faculty of Pharmacy and Pharmaceutical Sciences, University
of Alberta, Edmonton
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Lewis S, La Brooy C, Kerridge I, Holmes A, Olver I, Hudson P, Dooley M, Komesaroff P. Choreographing a good death: Carers' experiences and practices of enacting assisted dying. SOCIOLOGY OF HEALTH & ILLNESS 2024. [PMID: 38386331 DOI: 10.1111/1467-9566.13761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2023] [Accepted: 01/31/2024] [Indexed: 02/23/2024]
Abstract
The proliferation of assisted dying legislative reforms globally is a significant change in the social and medico-legal landscape of end-of-life care. Understanding the impacts of these legislative reforms on family members who care for a dying person is vital, yet under-theorised in research. In this article, drawing on semi-structured interviews with 42 carers for a person who has sought assisted dying in Australia, and extending ideas of ontological choreography we explore the new and complex choreographies enacted by carers in their endeavour to arrange a 'good death' for the dying person. We find that desires to fulfil the dying person's wishes are often accompanied by normative pressures, affective tensions and complexities in bereavement. Enacting assisted dying requires carers to perform a repertoire of highly-staged practices. Yet, institutional obstacles and normative cultural scripts of dying can constrain carer assisted dying practices. Understanding the nuances of carers' experiences and how they navigate this new end-of-life landscape, we argue, provides critical insights about how assisted dying legislation is producing new cultural touchpoints for caring at the end of life. Moreover, we show how emerging cultural scripts of assisted dying are impacting in the lives of these carers.
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Affiliation(s)
- Sophie Lewis
- Sydney School of Health Sciences, The University of Sydney, Sydney, New South Wales, Australia
| | | | - Ian Kerridge
- Sydney Health Ethics, University of Sydney, Sydney, New South Wales, Australia
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Alex Holmes
- Department of Psychiatry, University of Melbourne, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Ian Olver
- School of Psychology, University of Adelaide, Adelaide, South Australia, Australia
| | - Peter Hudson
- Centre for Palliative Care, St Vincent's Hospital Melbourne, Melbourne, Victoria, Australia
- School of Health Sciences, The University of Melbourne, Melbourne, Victoria, Australia
| | - Michael Dooley
- Alfred Health, Prahran, Victoria, Australia
- Centre for Medicine Use and Safety, Monash University, Parkville, Victoria, Australia
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Serota K, Buchman DZ, Atkinson M. Mapping MAiD Discordance: A Qualitative Analysis of the Factors Complicating MAiD Bereavement in Canada. QUALITATIVE HEALTH RESEARCH 2024; 34:195-204. [PMID: 37972933 PMCID: PMC10768327 DOI: 10.1177/10497323231208540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Medical assistance in dying (MAiD) is an evolving practice in Canada, with requests and outcomes increasing each year, and yet controversy is present-with a vast spectrum of ethical positions on its permissibility. International research indicates that family members who experience disagreement over their loved one's decision to have MAiD are less likely to be actively involved in supporting patients through the practical aspects of the dying process. Family members with passive involvement in the assisted dying process may also experience more significant moral dilemmas and challenging grief experiences than those who supported the decision. Given these previous findings, we designed this study to explore the factors complicating family members' experiences with MAiD in Canada and to understand how these complicating factors impact family members' bereavement in the months and years following MAiD. We conducted narrative interviews with 12 MAiD-bereaved family members who experienced disagreements, family conflicts, or differences in understanding about MAiD. Documenting and analyzing participants' experiences through storytelling allowed us to appreciate the complexity of family members' experiences and understand their values. The analysis generated five factors that can complicate the MAiD process and bereavement for family members: family discordance, internal conflict, legislative and eligibility concerns, logistical challenges, and managing disclosure and negative reactions. To our knowledge, this is the first Canadian study that explores how family discordance can impact bereavement following MAiD. Future bereavement services and resources should consider how these complicating factors may impact bereavement and ensure that Canadians with diverse MAiD experiences can access appropriate support.
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Affiliation(s)
- Kristie Serota
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Daniel Z. Buchman
- Centre for Addiction and Mental Health (CAMH), Toronto, ON, Canada
- Joint Centre for Bioethics, University of Toronto, Toronto, ON, Canada
| | - Michael Atkinson
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
- Kinesiology and Physical Education, University of Toronto, Toronto, ON, Canada
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Philip J, Le B, La Brooy C, Olver I, Kerridge I, Komesaroff P. Voluntary Assisted Dying/Euthanasia: Will This Have an Impact on Cancer Care in Future Years? Curr Treat Options Oncol 2023; 24:1351-1364. [PMID: 37535255 PMCID: PMC10547610 DOI: 10.1007/s11864-023-01126-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/22/2023] [Indexed: 08/04/2023]
Abstract
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.
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Affiliation(s)
- Jennifer Philip
- Department of Medicine, University of Melbourne, Victoria Pde, Fitzroy 3065, Melbourne, Victoria, Australia.
- Palliative Care Service, St Vincent's Hospital, Melbourne, Victoria, Australia.
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre & Royal Melbourne Hospital, Melbourne, Victoria, Australia.
| | - Brian Le
- Department of Medicine, University of Melbourne, Victoria Pde, Fitzroy 3065, Melbourne, Victoria, Australia
- Parkville Integrated Palliative Care Service, Peter MacCallum Cancer Centre & Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Camille La Brooy
- Public Health & Preventive Medicine, Monash University, Monash, Victoria, Australia
| | - Ian Olver
- University of Notre Dame of Australia, Sydney, NSW, Australia
| | - Ian Kerridge
- Haematology Department, Royal North Shore Hospital, St Leonards, NSW, Australia
- Sydney Health Ethics, University of Sydney, Sydney, NSW, Australia
- Department of Philosophy, Macquarie University, Macquarie, NSW, Australia
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Pottash M, Saikaly K, Stevenson M, Krohmal B. A Survey of Clinicians Who Provide Aid in Dying. Am J Hosp Palliat Care 2023:10499091231205841. [PMID: 37776055 DOI: 10.1177/10499091231205841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION Little is known about the identity and moral experience of clinicians who provide the option of aid in dying to terminally ill Americans. METHODS In May 2023 we distributed an email survey to clinicians registered for the American Clinician's Academy on Medical Aid in Dying listserv. RESULTS Of the 72 clinicians who responded, 90% were of white race, 50% were over 60 years old, and 47% had been in practice for over 20 years. Most clinicians report practicing primary care (39%) or hospice/palliative care (33%); 25% of clinicians had training in palliative medicine. 22% described their practice as a specialized "aid-in-dying practice" and 26% either "rarely" or "never" cared for the terminally ill outside the context of aid in dying. A majority (56%) of clinicians were either affiliated with an independent practice or unaffiliated. Before they began aid-in-dying work, 26% of clinicians reported having felt "somewhat" or "very" morally conflicted; after having written an aid in dying prescription, 96% felt "hardly" or "not at all" conflicted. On average, clinicians felt that aid-in-dying laws balance protection of patients with access; 39% believed that the laws were "somewhat" or "overly" protective. CONCLUSION Many responding clinicians report caring for patients considering aid in dying in specialized practices or otherwise in unaffiliated or independent practice. Clinicians report that providing aid in dying (and writing an aid-in-dying prescription) resulted in less reported moral conflict toward aid in dying.
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Affiliation(s)
- Michael Pottash
- Georgetown University School of Medicine, Washington, DC, USA
- Division of Palliative Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Kayla Saikaly
- Georgetown University School of Medicine, Washington, DC, USA
| | - Maximilian Stevenson
- Division of Palliative Medicine, MedStar Washington Hospital Center, Washington, DC, USA
| | - Benjamin Krohmal
- Georgetown University School of Medicine, Washington, DC, USA
- John J Lynch Center for Ethics, MedStar Washington Hospital Center, Washington, DC, USA
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Close E, Jeanneret R, Downie J, Willmott L, White BP. A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change. BMC Med Ethics 2023; 24:71. [PMID: 37735387 PMCID: PMC10512474 DOI: 10.1186/s12910-023-00950-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Accepted: 08/31/2023] [Indexed: 09/23/2023] Open
Abstract
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.
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Affiliation(s)
- Eliana Close
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4000, Australia.
| | - Ruthie Jeanneret
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4000, Australia
| | - Jocelyn Downie
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4000, Australia
- Health Law Institute, Faculties of Law and Medicine, Dalhousie University, Halifax, Canada
| | - Lindy Willmott
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4000, Australia
| | - Ben P White
- Australian Centre for Health Law Research, Faculty of Business and Law, Queensland University of Technology, GPO Box 2434, Brisbane, QLD, 4000, Australia
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9
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Buchbinder M. MAID in America: Expanding Our Gaze on the Ethics of Assistance. THE AMERICAN JOURNAL OF BIOETHICS : AJOB 2023; 23:22-24. [PMID: 37647485 DOI: 10.1080/15265161.2023.2237444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
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10
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Crumley ET, LeBlanc J, Henderson B, Jackson-Tarlton CS, Leck E. Canadian family members' experiences with guilt, judgment and secrecy during medical assistance in dying: a qualitative descriptive study. CMAJ Open 2023; 11:E782-E789. [PMID: 37607750 PMCID: PMC10449018 DOI: 10.9778/cmajo.20220140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND Although research briefly mentions that family members have encountered unexpected experiences during the medical assistance in dying (MAiD) process, from keeping MAiD a secret, to being judged and feeling guilty, the potential implications of these are less understood. This study's aim was to examine guilt, judgment and secrecy as part of the MAiD experiences of family members in Canada. METHODS We conducted a qualitative descriptive study with 1-hour semistructured interviews by telephone or video from December 2020 to December 2021. Through local and national organizations, we recruited Canadian family members with MAiD experience. A subset analysis of unexpected experiences was conducted, which identified 3 categories: guilt, judgment and secrecy. Similar codes were grouped together within each category into themes. Participants were sent the draft manuscript and their suggestions were integrated. RESULTS A total of 45 family members from 6 provinces who experienced MAiD from 2016 to 2021 participated. Many people who had MAiD were diagnosed with cancer, comorbidities or neurologic disease. Some participants unexpectedly found themselves managing guilt, judgment and/or secrecy, which may complicate their grieving and bereavement. Numerous participants experienced judgment from relatives, friends, religious people and/or health care professionals. Many kept MAiD secret because they were not allowed to tell or for religious reasons, and/or selectively told others. INTERPRETATION Family members said they were ill-prepared to manage their experiences of guilt, judgment and secrecy during the MAiD process. MAiD programs and assessors/providers could provide family-specific information to help lessen these burdens and better prepare relatives for common, yet unexpected, experiences they may encounter.
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Affiliation(s)
- Ellen T Crumley
- Faculties of Management (Crumley) and Medicine (Leck, Henderson, Jackson-Tarlton), Dalhousie University, Halifax, NS; Health Program (LeBlanc), St. Francis Xavier University, Antigonish, NS
| | - Jocelyne LeBlanc
- Faculties of Management (Crumley) and Medicine (Leck, Henderson, Jackson-Tarlton), Dalhousie University, Halifax, NS; Health Program (LeBlanc), St. Francis Xavier University, Antigonish, NS
| | - Brett Henderson
- Faculties of Management (Crumley) and Medicine (Leck, Henderson, Jackson-Tarlton), Dalhousie University, Halifax, NS; Health Program (LeBlanc), St. Francis Xavier University, Antigonish, NS
| | - Caitlin S Jackson-Tarlton
- Faculties of Management (Crumley) and Medicine (Leck, Henderson, Jackson-Tarlton), Dalhousie University, Halifax, NS; Health Program (LeBlanc), St. Francis Xavier University, Antigonish, NS
| | - Erika Leck
- Faculties of Management (Crumley) and Medicine (Leck, Henderson, Jackson-Tarlton), Dalhousie University, Halifax, NS; Health Program (LeBlanc), St. Francis Xavier University, Antigonish, NS
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Xu H, Stjernswärd S, Glasdam S, Fu C. Circumstances affecting patients' euthanasia or medically assisted suicide decisions from the perspectives of patients, relatives, and healthcare professionals: A qualitative systematic review. DEATH STUDIES 2023; 48:326-351. [PMID: 37390123 DOI: 10.1080/07481187.2023.2228730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/02/2023]
Abstract
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.
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Affiliation(s)
- Hongxuan Xu
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Sigrid Stjernswärd
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Stinne Glasdam
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
| | - Cong Fu
- Department of Health Sciences, Faculty of Medicine, Lund University, Lund, Sweden
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Tong E, Nissim R, Selby D, Bean S, Isenberg-Grzeda E, Thangarasa T, Rodin G, Li M, Hales S. The impact of COVID-19 on the experiences of patients and their family caregivers with medical assistance in dying in hospital. BMC Palliat Care 2023; 22:70. [PMID: 37312178 DOI: 10.1186/s12904-023-01191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 06/03/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND The COVID-19 pandemic and its containment measures have drastically impacted end-of-life and grief experiences globally, including those related to medical assistance in dying (MAiD). No known qualitative studies to date have examined the MAiD experience during the pandemic. This qualitative study aimed to understand how the pandemic impacted the MAiD experience in hospital of persons requesting MAiD (patients) and their loved ones (caregivers) in Canada. METHODS Semi-structured interviews were conducted with patients who requested MAiD and their caregivers between April 2020 and May 2021. Participants were recruited during the first year of the pandemic from the University Health Network and Sunnybrook Health Sciences Centre in Toronto, Canada. Patients and caregivers were interviewed about their experience following the MAiD request. Six months following patient death, bereaved caregivers were interviewed to explore their bereavement experience. Interviews were audio-recorded, transcribed verbatim, and de-identified. Transcripts were analyzed using reflexive thematic analysis. RESULTS Interviews were conducted with 7 patients (mean [SD] age, 73 [12] years; 5 [63%] women) and 23 caregivers (mean [SD] age, 59 [11] years; 14 [61%] women). Fourteen caregivers were interviewed at the time of MAiD request and 13 bereaved caregivers were interviewed post-MAiD. Four themes were generated with respect to the impact of COVID-19 and its containment measures on the MAiD experience in hospital: (1) accelerating the MAiD decision; (2) compromising family understanding and coping; (3) disrupting MAiD delivery; and (4) appreciating rule flexibility. CONCLUSIONS Findings highlight the tension between respecting pandemic restrictions and prioritizing control over the dying circumstances central to MAiD, and the resulting impact on patient and family suffering. There is a need for healthcare institutions to recognize the relational dimensions of the MAiD experience, particularly in the isolating context of the pandemic. Findings may inform strategies to better support those requesting MAiD and their families during the pandemic and beyond.
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Affiliation(s)
- Eryn Tong
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, Toronto, ON, Canada
| | - Rinat Nissim
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, Toronto, ON, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Debbie Selby
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Sally Bean
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Elie Isenberg-Grzeda
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Tharshika Thangarasa
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, Toronto, ON, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Gary Rodin
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, Toronto, ON, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Madeline Li
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, Toronto, ON, Canada
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sarah Hales
- Department of Supportive Care, Princess Margaret Cancer Centre, University Health Network, 620 University Avenue, Toronto, ON, Canada.
- Department of Psychiatry, Faculty of Medicine, University of Toronto, Toronto, ON, Canada.
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Bravo G, Delli Colli N, Dumont I, Bouthillier ME, Rochette M, Trottier L. Social workers' experiences with medical assistance in dying: Survey findings from Quebec, Canada. SOCIAL WORK IN HEALTH CARE 2023; 62:193-205. [PMID: 37183409 DOI: 10.1080/00981389.2023.2210624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
As part of a larger survey, we asked social workers whether they had been involved in medical assistance in dying (MAID) so far. Of the 367 survey participants, 141 reported that they had. These were invited to describe their roles, needs, and sense of competence, focusing on their last MAID experience. Roles were diversified, beginning before and extending beyond the provision of MAID. Nearly 60% needed training on MAID. Perceived competence was lower among those lacking training. Findings point to educational needs that must be addressed to ensure the quality of end-of-life care and the well-being of social workers who engage in MAID.
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Affiliation(s)
- Gina Bravo
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
- Department of Community Health Sciences, Faculty of Medicine and Health Sciences, Université de Sherbrooke, Sherbrooke, Canada
| | - Nathalie Delli Colli
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
- School of Social Work, Université de Sherbrooke, Sherbrooke, Canada
| | - Isabelle Dumont
- School of Social Work, Université du Québec à Montréal, Montréal, Canada
| | - Marie-Eve Bouthillier
- Office of Clinical Ethics, Faculty of Medicine, Université de Montréal, Montréal, Canada
| | - Marianne Rochette
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
- Pragmatic Health Ethics Research Unit, Institut de recherches cliniques de Montréal, Montréal, Canada
| | - Lise Trottier
- CIUSSS de l'Estrie - CHUS, Research Centre on Aging, Sherbrooke, Canada
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Mulder J, Sonneveld H, Van Raemdonck D, Downar J, Wiebe K, Domínguez-Gil B, Healey A, Desschans B, Neyrinck A, Blanco AP, van Dusseldorp I, Olthuis G. Practice and challenges for organ donation after medical assistance in dying: A scoping review including the results of the first international roundtable in 2021. Am J Transplant 2022; 22:2759-2780. [PMID: 36100362 PMCID: PMC10092544 DOI: 10.1111/ajt.17198] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Revised: 09/01/2022] [Accepted: 09/07/2022] [Indexed: 01/25/2023]
Abstract
The procedure combining medical assistance in dying (MAiD) with donations after circulatory determination of death (DCDD) is known as organ donation after euthanasia (ODE). The first international roundtable on ODE was held during the 2021 WONCA family medicine conference as part of a scoping review. It aimed to document practice and related issues to advise patients, professionals, and policymakers, aiding the development of responsible guidelines and helping to navigate the issues. This was achieved through literature searches and national and international stakeholder meetings. Up to 2021, ODE was performed 286 times in Canada, the Netherlands, Spain, and Belgium, including eight cases of ODE from home (ODEH). MAiD was provided 17,217 times (2020) in the eight countries where ODE is permitted. As of 2021, 837 patients (up to 14% of recipients of DCDD donors) had received organs from ODE. ODE raises some important ethical concerns involving patient autonomy, the link between the request for MAiD and the request to donate organs and the increased burden placed on seriously ill MAiD patients.
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Affiliation(s)
- Johannes Mulder
- Anesthesiology/Intensive Care Department, Isala Hospitals, Zwolle, The Netherlands.,Family Medicine Centre Dalfsen, Zwolle, The Netherlands
| | - Hans Sonneveld
- Anesthesiology/Intensive Care Department, Isala Hospitals, Zwolle, The Netherlands
| | | | - James Downar
- Department of Critical Care, University of Ottawa, Ottawa, Canada
| | - Kim Wiebe
- Shared Health Services, Canada, Winnipeg, Canada
| | | | - Andrew Healey
- Intensive Care Department, William Osler Health System Hospitals, Brampton, Canada.,Trillium Gift of Life Donation, Canada
| | - Bruno Desschans
- Transplant Centre Leuven, University Hospital Leuven, Leuven, Belgium
| | - Arne Neyrinck
- Transplant Centre Leuven, University Hospital Leuven, Leuven, Belgium
| | | | - Ingeborg van Dusseldorp
- Knowledge Institute of the Dutch Association of Medical Specialists, Utrecht, The Netherlands
| | - Gert Olthuis
- IQ healthcare, Radboud Institute for Health Sciences, Radboud University Medical Center, Nijmegen, The Netherlands
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15
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Variath C, Peter E, Cranley L, Godkin D. Experiences of healthcare providers with eligible patients' loss of decision-making capacity while awaiting medical assistance in dying. Palliat Care Soc Pract 2022; 16:26323524221128839. [PMID: 36268274 PMCID: PMC9577066 DOI: 10.1177/26323524221128839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/06/2022] [Indexed: 11/09/2022] Open
Abstract
Background In Canada, under Bill C-14, patients who met all eligibility requirements were prevented from accessing medical assistance in dying (MAiD) following their loss of decision-making capacity while awaiting MAiD. The changes introduced with Bill C-7 continue to limit access to patients who did not enter a waiver of final consent agreement with their healthcare providers. Little is known about the experiences with patients' loss of capacity to consent and subsequent ineligibility for MAiD. Understanding healthcare providers' experiences has important implications for improving end-of-life care for those with capacity-limiting conditions. Purpose To explore Canadian healthcare providers' experiences with end-of-life of eligible patients who became ineligible for MAiD due to their loss of decision-making capacity to consent and the relational influences on their experiences prior to the implementation of Bill C-7 in Canada. Method A critical qualitative methodology and a feminist ethics theoretical lens guided this study. A voice-centred relational approach that allowed an in-depth exploration of how power, relationality and moral agency influenced participants' experiences was used for data analysis. Data consisted of semi-structured interviews with 30 healthcare providers. Findings The analysis resulted in the following four main themes and corresponding subthemes: (1) identifying factors that may result in ineligibility for MAiD due to capacity loss; (2) maintaining eligibility required to access MAiD; (3) preparing for an alternative end-of-life; (4) experiencing patients' capacity loss. Discussion This study highlights that while MAiD is legally available to eligible Canadians, access to MAiD and care for eligible patients who were unable to access MAiD due to their loss of decision-making varied based on the geographical locations and access to willing MAiD and end-of-life care providers. The availability of high-quality palliative care for patients throughout the MAiD process, including following the loss of capacity to consent and subsequent ineligibility, would improve the end-of-life experience for all those involved. The need to establish a systematic approach to prepare and care for patients and their families following the patients' loss of capacity and subsequent ineligibility for MAiD is also identified.
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Affiliation(s)
| | - Elizabeth Peter
- Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto, Toronto, ON, CanadaJoint Centre for Bioethics,
University of Toronto, Toronto, ON, Canada
| | - Lisa Cranley
- Lawrence S. Bloomberg Faculty of Nursing,
University of Toronto, Toronto, ON, Canada
| | - Dianne Godkin
- Trillium Health Partners-Mississauga Hospital,
Mississauga, ON, CanadaLawrence S. Bloomberg Faculty of Nursing, University
of Toronto, Toronto, ON, CanadaJoint Centre for Bioethics, University of
Toronto, Toronto, ON, Canada
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16
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Variath C, Climans SA, Edelstein K, Bell JAH. Neuro-oncology clinicians' perspectives on factors affecting brain cancer patients' access to medical assistance in dying: A qualitative study. DEATH STUDIES 2022; 47:296-306. [PMID: 35442866 DOI: 10.1080/07481187.2022.2063456] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In most jurisdictions where medical assistance in dying (MAiD) is legal, patients must have decision-making capacity. Brain cancer often damages the cognitive networks required to maintain decision-making capacity. Using qualitative methodology guided by a relational ethics conceptual framework, this study explored neuro-oncology clinicians' perspectives on access to and eligibility for MAiD for patients diagnosed with brain cancer. We interviewed 24 neuro-oncology clinicians from 6 countries. Participants described the unique challenges facing brain cancer patients, potentially resulting in their inequitable access to MAiD. The findings highlight the importance of early end-of-life conversations, advance care planning, and access to end-of-life treatment options.
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Affiliation(s)
- Caroline Variath
- Lawrence S Bloomberg School of Nursing, Joint Centre for Bioethics, University of Toronto, Toronto, Canada
| | - Seth A Climans
- Departments of Neurology and Medical Oncology and Hematology, Princess Margaret Cancer Centre, Toronto, Canada
| | - Kim Edelstein
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada
| | - Jennifer A H Bell
- Department of Psychiatry, University of Toronto, Toronto, Canada
- Department of Supportive Care, Princess Margaret Cancer Centre, Toronto, Canada
- Dalla Lana School of Public Health, Joint Centre for Bioethics, University of Toronto, Toronto, Canada
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17
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Laperle P, Achille M, Ummel D. To Lose a Loved One by Medical Assistance in Dying or by Natural Death with Palliative Care: A Mixed Methods Comparison of Grief Experiences. OMEGA-JOURNAL OF DEATH AND DYING 2022:302228221085191. [PMID: 35420908 DOI: 10.1177/00302228221085191] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
The integration of assisted dying into end-of-life care is raising reflections on bereavement. Patients and families may be faced with a choice between this option and natural death assisted by palliative care; a choice that may affect grief. Therefore, this study describes and compares grief experiences of individuals who have lost a loved one by medical assistance in dying or natural death with palliative care. A mixed design was used. Sixty bereaved individuals completed two grief questionnaires. The qualitative component consisted of 16 individual semi-structured interviews. We found no statistically significant differences between medically assisted and natural deaths, and scores did not suggest grief complications. Qualitative results are nuanced: positive and negative imprints may influence grief in both contexts. Hastened and natural deaths are death circumstances that seem to generally help ease mourning. However, they can still, in interaction with other risk factors, produce difficult experiences for some family caregivers.
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Affiliation(s)
- Philippe Laperle
- Department of Psychology, 141639Université de Montréal, Montreal, Canada
| | - Marie Achille
- Department of Psychology, 141639Université de Montréal, Montreal, Canada
| | - Deborah Ummel
- Department of Psychoeducation, 7321Université de Sherbrooke, Longueuil, Canada
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18
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Variath C, Peter E, Cranley L, Godkin D. Health care providers’ ethical perspectives on waiver of final consent for Medical Assistance in Dying (MAiD): a qualitative study. BMC Med Ethics 2022; 23:8. [PMID: 35094703 PMCID: PMC8801041 DOI: 10.1186/s12910-022-00745-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 01/14/2022] [Indexed: 01/21/2023] Open
Abstract
Abstract
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.
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19
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Joolaee S, Ho A, Serota K, Hubert M, Buchman DZ. Medical assistance in dying legislation: Hospice palliative care providers' perspectives. Nurs Ethics 2021; 29:231-244. [PMID: 34538192 PMCID: PMC8866752 DOI: 10.1177/09697330211012049] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND After over 4 years since medical assistance in dying legalization in Canada, there is still much uncertainty about how this ruling has affected Canadian society. OBJECTIVE To describe the positive aspects of medical assistance in dying legalization from the perspectives of hospice palliative care providers engaging in medical assistance in dying. DESIGN In this qualitative descriptive study, we conducted an inductive thematic analysis of semi-structured interviews with hospice palliative care providers. PARTICIPANTS AND SETTING Multi-disciplinary hospice palliative care providers in acute, community, residential, and hospice care in Vancouver and Toronto, Canada, who have engaged in end-of-life care planning with patients who have inquired about and/or requested medical assistance in dying. ETHICAL CONSIDERATIONS The research proposal was approved by University of British Columbia Research Ethics Board in Vancouver and University Health Network in Toronto. Participants were informed regarding the research goals, signed a written consent, and were assigned pseudonyms. RESULTS The 48 participants included hospice palliative care physicians (n = 22), nurses (n = 15), social workers (n = 7), and allied health providers (n = 4). The average interview length was 50 min. Positive aspects of medical assistance in dying legalization were identified at (1) the individual level: (a) a new end-of-life option, (b) patients' last chance to express control over their lives, (c) patient and family comfort and relief, and (d) a unique learning experience for hospice palliative care providers; (2) the team level: (a) supportive collegial relationships, (b) broadened discussions about end-of-life and palliative care, and (c) team debriefs provide opportunities for education and support; and (3) the institutional level: (a) improved processes to facilitate the implementation logistics. CONCLUSION While being involved in the medical assistance in dying process is complex and challenging, this study sheds light on the positive aspects of medical assistance in dying legalization from the hospice palliative care provider's perspectives. Medical Assistance in Dying legalization has resulted in improved end-of-life conversations between hospice palliative care providers, patients, and their families. Improved communication leads to a better understanding of patients' end-of-life care plans and bridges some of the existing gaps between hospice palliative care and medical assistance in dying.
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Affiliation(s)
- Soodabeh Joolaee
- Department of Evaluation and Research Services (DERS) Fraser Health, BC, Canada; Iran University of Medical Sciences, Iran
| | - Anita Ho
- University of British Columbia, Canada; University of California, USA; Centre for Health Evaluation and Outcome Sciences (CHÉOS), Canada
| | | | | | - Daniel Z Buchman
- Centre for Addiction and Mental Health, Canada; Krembil Research Institute, Canada; University of Toronto, Canada
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20
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Crumley ET, Kelly S, Young J, Phinney N, McCarthy J, Gubitz G. How is the medical assistance in dying (MAID) process carried out in Nova Scotia, Canada? A qualitative process model flowchart study. BMJ Open 2021; 11:e048698. [PMID: 34312206 PMCID: PMC8314721 DOI: 10.1136/bmjopen-2021-048698] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
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.
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Affiliation(s)
- Ellen T Crumley
- Health, Saint Francis Xavier University, Antigonish, Nova Scotia, Canada
| | - Scarlett Kelly
- Treasury Board of Canada Secretariat, Ottawa, Ontario, Canada
| | - Joel Young
- Dalhousie Medical School, Halifax, Nova Scotia, Canada
| | - Nicole Phinney
- Medical Assistance in Dying Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - John McCarthy
- Medical Assistance in Dying Program, Nova Scotia Health Authority, Halifax, Nova Scotia, Canada
| | - Gordon Gubitz
- Neurology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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