The rocks and hard places of MAiD: a qualitative study of nursing practice in the context of legislated assisted death

Canada's Medical Assistance in Dying System can Enable Healthcare Serial Killing

The Canadian approach to assisted dying, Medical Assistance in Dying (MAiD), as of early 2024, is assessed for its ability to protect patients from criminal healthcare serial killing (HSK) to evaluate the strength of its safeguards. MAiD occurs through euthanasia or self-administered assisted suicide (EAS) and is legal or considered in many countries and jurisdictions. Clinicians involved in HSK typically target patients with the same clinical features as MAiD-eligible patients. They may draw on similar rationales, e.g., to end perceived patient suffering and provide pleasure for the clinician. HSK can remain undetected or unconfirmed for considerable periods owing to a lack of staff background checks, poor surveillance and oversight, and a failure by authorities to act on concerns from colleagues, patients, or witnesses. The Canadian MAiD system, effectively euthanasia-based, has similar features with added opportunities for killing afforded by clinicians' exemption from criminal culpability for homicide and assisted suicide offences amid broad patient eligibility criteria. An assessment of the Canadian model offers insights for enhancing safeguards and detecting abuses in there and other jurisdictions with or considering legal EAS. Short of an unlikely recriminalization of EAS, better clinical safeguarding measures, standards, vetting and training of those involved in MAiD, and a radical restructuring of its oversight and delivery can help mitigate the possibility of abuses in a system mandated to accommodate homicidal clinicians.

Developing a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in Medical Assistance in Dying (MAiD): a mixed method modified e-Delphi study

BACKGROUND

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. Canada's legislation is the first to permit Nurse Practitioners (NP) to serve as independent MAiD assessors and providers. Registered Nurses' (RN) also have important roles in MAiD that include MAiD care coordination; client and family teaching and support, MAiD procedural quality; healthcare provider and public education; and bereavement care for family. Nurses have a right under the law to conscientious objection to participating in MAiD. Therefore, it is essential to prepare nurses in their entry-level education for the practice implications and moral complexities inherent in this practice. Knowing what nursing students think about MAiD is a critical first step. Therefore, the purpose of this study was to develop a survey to measure nursing students' knowledge, attitudes and beliefs, influences, and willingness to be involved in MAiD in the Canadian context.

METHODS

The design was a mixed-method, modified e-Delphi method that entailed item generation from the literature, item refinement through a 2 round survey of an expert faculty panel, and item validation through a cognitive focus group interview with nursing students. The settings were a University located in an urban area and a College located in a rural area in Western Canada.

RESULTS

During phase 1, a 56-item survey was developed from existing literature that included demographic items and items designed to measure experience with death and dying (including MAiD), education and preparation, attitudes and beliefs, influences on those beliefs, and anticipated future involvement. During phase 2, an expert faculty panel reviewed, modified, and prioritized the items yielding 51 items. During phase 3, a sample of nursing students further evaluated and modified the language in the survey to aid readability and comprehension. The final survey consists of 45 items including 4 case studies.

DISCUSSION

Systematic evaluation of knowledge-to-date coupled with stakeholder perspectives supports robust survey design. This study yielded a survey to assess nursing students' attitudes toward MAiD in a Canadian context.

CONCLUSION

The survey is appropriate for use in education and research to measure knowledge and attitudes about MAiD among nurse trainees and can be a helpful step in preparing nursing students for entry-level practice.

Rural healthcare professionals' participation in Medical Assistance in Dying (MAiD): beyond a binary decision

BACKGROUND

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016 and amended in 2021. At the time that this study was conducted, the federal government was considering expanding the eligibility criteria to include patients whose death was not reasonably foreseeable. The purpose of this study was to better understand rural healthcare professionals' experiences with assisted dying set against the backdrop of legislative expansion.

METHODS

A qualitative exploratory study was undertaken with general rural practice physicians, nurse practitioners, registered nurses, ethicists, patients, and patient families in rural Southern Alberta, Canada. For this paper, data from 18 audio-recorded and transcribed semi-structured interviews with healthcare professionals were analyzed using thematic analysis. Categories and patterns of shared meaning that linked to an overarching theme were identified.

RESULTS

Between the binary positions of full support for and conscientious objection to assisted dying, rural healthcare professionals' decisions to participate in MAiD was based on their moral convictions, various contextual factors, and their participation thresholds. Factors including patient suffering; personal and professional values and beliefs; relationships with colleagues, patients and family, and community; and changing MAiD policy and legislation created nuances that informed their decision-making.

CONCLUSIONS

The interplay of multiple factors and their degree of influence on healthcare professionals' decision-making create multiple decision points between full support for and participation in MAiD processes and complete opposition and/or abstention. Moreover, our findings suggest evolving policy and legislation have the potential to increase rural healthcare professionals' uncertainty and level of discomfort in providing services. We propose that the binary language typically used in the MAiD discourse be reframed to reflect that decision-making processes and actions are often fluid and situational.

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

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

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

OBJECTIVES

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

BACKGROUND

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

DESIGN

A qualitative descriptive approach was undertaken.

METHODS

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

FINDINGS

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

CONCLUSION

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

Medical aid in dying: The role of the nurse practitioner

ABSTRACT

Medical aid in dying (MAID) is a practice that has been expanding in the United States over the past few decades. As it becomes a viable option for a growing portion of the American population, nurse practitioners (NPs) need to be prepared to engage in conversation with patients about the practice. Although historically only physicians were able to participate in MAID, the role has recently expanded to include additional advanced practice providers, including NPs. Reviewing the history of MAID and examining how current legislation affects clinical practice can support the NP's ability to educate and counsel patients about the option. Identifying specific areas in which MAID providers report needing additional training and support can help providers work toward delivering the highest quality patient care possible. As MAID becomes accessible to greater numbers of people, NPs need to be prepared to talk to patients who are navigating serious, life-limiting illnesses about the possibility of MAID.

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

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

Reflections on the relational ontology of medical assistance in dying

Canadian nursing practice has been profoundly influenced by the legalization of medical assistance in dying in 2016, requiring that nurses navigate new and sometimes highly challenging experiences. Findings from our longitudinal studies of nurses' experiences suggest that these include deep emotional responses to medical assistance in dying, an urgency in orchestrating the perfect death, and a high degree of relational impact, both professionally and personally. Here we propose a theoretical explanation for these experiences based upon a relational ontology. Drawing upon the work of Wildman, we understand a relational ontology to be one in which relationships are more fundamentally central than the conceptual entities that provide the context to practice. It is in a relationship that conceptual entities, and their affiliated values, are created and recreated. Seen as causal, relationships have ontological status, with important implications for how we consider the concepts of death, suffering, and time in this context. From a conceptual perspective, suffering is primarily self-defined based upon personal histories, time reflects the potential remaining until death, and death is primarily biological and amoral, although social discourses of a good and bad death surround the death trajectory. However, within a relational ontology of medical assistance in dying, these understandings shift. Death becomes primarily social rather than biological, suffering is shared, and time until death is now clearly delimited. Accordingly, nurses assume a profound responsibility for influencing outcomes that are authentically person-centered. These understandings provide important insights into nurses' experiences, enabling us to recognize the causal effects, both intended and unintended, of nurses' relational practices amidst the complexities of assisted death. Drawing on such a perspective, we find implications for how we provide spaces for nurses to reflect on, and have conversations about, their experiences with some of the greatest mysteries of life-death, suffering, and time.

Medical Assistance in Dying: A Review of Canadian Health Authority Policy Documents

The purpose of this study was to describe policies developed by English-speaking Canadian health authorities to guide multi-disciplinary healthcare practice in the context of MAID. Seventeen policies from 9 provinces and 3 territories were identified and analyzed thematically. Themes developed from these documents related to ensuring a team approach to care, supporting informed patient choice, creating region-specific guidance on eligibility criteria and safeguards, accommodating conscientious objection, and making explicit organizational responsibilities. Ethical language concerned vulnerability, non-judgmental care, dignity, non-abandonment, confidentiality, moral conscience, and diverse cultural values. Overall, these policies addressed important risk mitigation strategies, acknowledged important social contracts, and supported ethical practice. Collectively, these policies outline important considerations in the evolving Canadian context for other jurisdictions seeking to create policy around assisted death.

Perception of roles across the interprofessional team for delivery of medical assistance in dying

In 2016, Canada joined many jurisdictions worldwide in legalizing Medical Assistance in Dying (MAiD). Given the paucity of qualitative research regarding the involvement of interprofessional health care providers (HCPs) in MAiD, the goal of this study was to better understand how HCPs viewed their role(s). Semi-structured interviews were conducted with 3 pharmacists, 10 nurses, and 8 social workers at an academic hospital in Toronto. Thematic analysis generated six broad themes: 1) Practical/Technical Component, 2) Education, 3) Support, 4) "Part of the Job," 5) "All of the Job," and 6) Lack of Published Information. While nurses and social workers espoused many commonalities, nursing roles were more "in the moment," whereas social workers viewed their roles as beginning earlier and extending after provision of MAiD. There was a spectrum of how participants perceived their role: pharmacists minimized the task of dispensing medications as an insignificant experience, nurses viewed involvement as consistent with their other professional duties (specifically non-MAiD deaths), and social workers described MAiD as a unique opportunity to employ the full gamut of their skills. The study highlights the importance of supporting HCPs through education and information at both regulatory and research levels, recognizing the key roles they play in MAiD.

Medical assistance in dying and the meaning of care: Perspectives of nurses, pharmacists, and social workers

Medical Assistance in Dying (MAiD) was legalized in Canada in 2016. While it has generated significant academic interest, the experiences of healthcare workers other than physicians remain understudied. This paper reports on a qualitative study of interprofessional Healthcare Providers (HCPs) involved in the provision of MAiD in order to: (1) characterize providers' views about the care they offer in general; (2) examine whether or not they consider MAiD a form of care; and (3) explore their reasons for viewing or not viewing MAiD as care. Semi-structured qualitative interviews were conducted with ten nurses, eight social workers, and three pharmacists with firsthand experience delivering MAiD at an academic hospital in Toronto, Canada. The study was approved by the hospital's REB. Written informed consent was obtained prior to participation. Codebook thematic analysis and template analysis generated four themes: (1) care as advocacy, (2) care as easing suffering, (3) care as psychosocial, and (4) care as relational. Every participant viewed MAiD as a form of care and drew on these four themes to authenticate MAiD as care. Participants consider MAiD a form of care for patients, families, other healthcare workers, and even themselves. In alternating and composite fashion, they describe MAiD in terms of autonomy, easing suffering, and a kind death for the dying (and those entrusted with their care)-a complex choreography of social discourses and moral logics that refuse to settle into a simple dichotomy of "choice versus care." Participants depict MAiD in many of the same terms and imagery they use to describe the care they offer in general. In light of ongoing social controversies surrounding MAiD, HCPs utilize a range of logics strategically to repel negative attention and enable their participation in what they see as a caring end for their patients.

Better Regulation of End-Of-Life Care: A Call For A Holistic Approach

Existing regulation of end-of-life care is flawed. Problems include poorly-designed laws, policies, ethical codes, training, and funding programs, which often are neither effective nor helpful in guiding decision-making. This leads to adverse outcomes for patients, families, health professionals, and the health system as a whole. A key factor contributing to the harms of current regulation is a siloed approach to regulating end-of-life care. Existing approaches to regulation, and research into how that regulation could be improved, have tended to focus on a single regulatory instrument (e.g., just law or just ethical codes). As a result, there has been a failure to capture holistically the various forces that guide end-of-life care. This article proposes a response to address this, identifying "regulatory space" theory as a candidate to provide the much-needed holistic insight into improving regulation of end-of-life care. The article concludes with practical implications of this approach for regulators and researchers.

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.

Death-coping self-efficacy and its influencing factors among Chinese nurses: A cross-sectional study

Background

Nurses are the main caregivers of dying patients. Facing or dealing with death-related events is inevitable. Death-coping self-efficacy (DCS) is very important, as it can reduce the risk of nursing staff to adverse emotional distress, help them participate in end-of-life care and improve the quality of care of patients.

Methods

Using the convenient sampling method, this study included a total of 572 nurses from a tertiary hospital in Hangzhou, China. The status and influencing factors of the DCS of nurses were explored using a general information questionnaire and DCS scale.

Results

The scores of each parameter, ranging from low to high, were in the order of coping with grief, preparation for death and hospice care. Factors influencing nurses’ DCS included attendance in hospice care education courses within the previous year, experience of accompanying the family members of the deceased and attitude towards death.

Conclusions

The overall self-efficacy of nurses in palliative care was at a medium level. Moreover, their self-efficacy in coping with grief and preparation for death should be strengthened. Managers of medical institutions can assess the death-coping ability of nurses, which helps provide corresponding support and training for nurses at an early stage. Nurses should receive guidance in grief adjustment and emotion regulation. Medical units should provide nurses with a platform for continuous training and education, use of death-related theoretical models and frameworks to guide nurses in dealing with death-related events, reduce nurses’ negative mood and jointly promote their mental health.

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.

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

BACKGROUND

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

RESEARCH QUESTION/AIM/OBJECTIVES

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

RESEARCH DESIGN

A grounded theory design was used.

PARTICIPANTS AND RESEARCH CONTEXT

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

ETHICAL CONSIDERATIONS

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

FINDINGS/RESULTS

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

CONCLUSIONS

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

Nurses' attitudes toward, perceptions of, and experiences with conscientious objection

BACKGROUND

Conscientious objection is a person's refusal to fulfill a legal duty due to their ethical values, religious beliefs, or ideological affiliations. In nursing, it refers to a nurse's refusal to perform an action or participate in a particular situation based on their conscience. Conscientious objection has become a highly contested topic in recent years.

RESEARCH OBJECTIVES

This study had four objectives: (1) eliciting information on how Turkish nurses perceive conscientious objection, (2) revealing whether their moral beliefs affect the care they provide, (3) determining their experiences with conscientious objection, and (4) identifying existing or potential issues of conscientious objection.

RESEARCH DESIGN

This qualitative study collected data through semi-structured interviews. The data were analyzed using thematic content analysis.

PARTICIPANTS

The sample consisted of 21 nurses.

ETHICAL CONSIDERATIONS

The study was approved by an ethics committee. Confidentiality and anonymity were guaranteed. Participation was voluntary.

FINDINGS

The analysis revealed four themes: (1) universal values of nursing (professional values), (2) experiences with conscientious objection (refusing to provide care/not providing care), (3) possible effects of conscientious objection (positive and negative), and (4) scope of conscientious objection (grounded and groundless).

CONCLUSION

Participants did not want to provide care due to (1) patient characteristics or (2) their own religious and moral beliefs. Participants stated that conscientious objection should be limited in the case of moral dilemmas and accepted only if the healthcare team agreed on it. Further research is warranted to define conscientious objection and determine its possible effects, feasibility, and scope in Turkey.

Odnos medicinskih sester do evtanazije

Uvod: Evtanazija je pojem, o katerem se mora razpravljati z vidika medicinskih, zdravstvenih in družboslovnih strok. Medicinske sestre so sestavni del zdravstvenih timov, zato je potrebno njihovo vključevanje v etične razprave o evtanaziji. Namen pregleda literature je predstaviti vidik evtanazije v povezavi z zdravstveno nego.Metode: Uporabljen je bil pregled literature, izveden v podatkovnih bazah COBIB.SI, CIHAHL in PubMed od 1. 11. 2020 do 1. 12. 2020. Iskanje je potekalo z uporabo ključnih besed: »evtanazija«, »zdravstvena nega«, v angleškem jeziku s kombinacijo ključnih besed: »attitudes«, »euthanasia« in »nursing«. Potek pregleda literature je prikazan z diagramom PRISMA. Kakovost virov, vključenih v končno analizo, je bila ocenjena s pomočjo hierarhije dokazov. Rezultati so bili sintetizirani z uporabo tematske analize.Rezultati: Izmed 138 virov je bilo v končno analizo vključenih enaindvajsetih člankov. Medicinske sestre so navajale naklonjen, kot tudi nenaklonjen odnos ter prisotnost etičnih dilem v povezavi z evtanazijo. Naklonjen odnos medicinskih sester do evtanazije se kaže v primerih neobvladljivih bolečin, neznosnega trpljenja in neozdravljivih bolezni, nenaklonjen pa v povezavi z nekaterimi demografskimi in kulturnimi značilnostmi medicinskih sester, upoštevanjem načel sočutne oskrbe in spoštovanjem vrednosti človekovega življenja.Diskusija in zaključek: Ugotovitve raziskave prispevajo prepoznati odnos medicinskih sester do evtanazije ter nekatere etične dileme v povezavi z evtanazijo. Potrebno bi bilo izvesti podrobne preglede etičnih dilem in moralnih stisk, ki se pojavljajo v povezavi z evtanazijo in zdravstveno nego.

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.

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

Background

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

Method

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

Results

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

Discussion

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

Physician-Patient Relationship, Assisted Suicide and the Italian Constitutional Court

In 2017, Italy passed a law that provides for a systematic discipline on informed consent, advance directives, and advance care planning. It ranges from decisions contextual to clinical necessity through the tool of consent/refusal to decisions anticipating future events through the tools of shared care planning and advance directives. Nothing is said in the law regarding the issue of physician assisted suicide. Following the DJ Fabo case, the Italian Constitutional Court declared the constitutional illegitimacy of article 580 of the criminal code in the part in which it does not exclude the punishment of those who facilitate the suicide when the decision has been freely and autonomously made by a person kept alive by life-support treatments and suffering from an irreversible pathology, the source of physical or psychological suffering that he/she considers intolerable, but fully capable of making free and conscious decisions. Such conditions and methods of execution must be verified by a public structure of the national health service, after consulting the territorially competent ethics committee. This statement admits, within strict and regulated bounds, physician assisted suicide, so widening the range of end-of-life decisions for Italian patients. Future application and critical topics will be called into question by the Italian legislator.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

Background

Even as healthcare providers and systems were settling into the processes required for Medical Assistance in Dying (MAID) under Bill C-14, new legislation was introduced (Bill C-7) that extended assisted death to persons whose natural death is not reasonably foreseeable. The purpose of this paper is to describe the experiences of nurses and nurse practitioners with the implementation and ongoing development of this transition.

Methods

This qualitative longitudinal descriptive study gathered data through semi-structured telephone interviews with nurses from across Canada; cross sectional data from 2020 to 2021 is reported here. The study received ethical approval and all participants provided written consent.

Findings

Participants included nurses (n = 34) and nurse practitioners (n = 16) with significant experience with MAID. Participants described how MAID had transitioned from a new, secretive, and anxiety-producing procedure to one that was increasingly visible and normalized, although this normalization did not necessarily mitigate the emotional impact. MAID was becoming more accessible, and participants were learning to trust the process. However, the work was becoming increasingly complex, labour intensive, and often poorly remunerated. Although many participants described a degree of integration between MAID and palliative care services, there remained ongoing tensions around equitable access to both. Participants described an evolving gestalt of determining persons’ eligibility for MAID that required a high degree of clinical judgement. Deeming someone ineligible was intensely stressful for all involved and so participants had learned to be resourceful in avoiding this possibility. The required 10-day waiting period was difficult emotionally, particularly if persons worried about losing capacity to give final consent. The implementation of C-7 was perceived to be particularly challenging due to the nature of the population that would seek MAID and the resultant complexity of trying to address the origins of their suffering within a resource-strapped system.

Conclusions

Significant social and system calibration must occur to accommodate assisted death as an end-of-life option. The transition to offering MAID for those whose natural death is not reasonably foreseeable will require intensive navigation of a sometimes siloed and inaccessible system. High quality MAID care should be both relational and dialogical and those who provide such care require expert communication skills and knowledge of the healthcare system.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12913-021-07222-5.

Conscience and conscientious objection in nursing: A personalist bioethics approach

The ability of nurses to act as moral agents in accordance with their conscience is both an essential human freedom and an important part of professional ethics. Recent developments in Canada related to Medical Assistance in Dying have revealed new and important challenges related to conscientious objection - challenges that may require rethinking of how nurses do professional ethics. Notably, the inclusion of a personalist bioethical approach is needed to introduce and explicate what conscience is for nurses to be able to apply it to nursing practice. In this article, we explore the importance of conscience and conscientious objection as ethical concepts to support nurses in addressing issues of conscience amid ethically challenging situations. We discuss how a personalist basis for conscience can support nurses to inclusively engage with one another across diverse moral perspectives.

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

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

Medical assistance in dying legislation: Hospice palliative care providers' perspectives

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.

The Ethics of Dying: Deciphering Pandemic-Resultant Pressures That Influence Elderly Patients' Medical Assistance in Dying (MAiD) Decisions

The objective of medicine is to provide humans with the best possible health outcomes from the beginning to the end of life. If the continuation of life becomes unbearable, some may evaluate procedures to end their lives prematurely. One such procedure is Medical Assistance in Dying (MAiD), and it is hotly contended in many spheres of society. From legal to personal perspectives, there are strong arguments for its implementation and prohibition. This article intends to add to this rich discourse by exploring MAiD in the context of our current pandemic-ridden society as new pressures from social isolation and guilt threaten the autonomy of vulnerable elderly patients. Although autonomy is of chief importance, variables within our current context undermine otherwise independent decisions. Many older individuals are isolated from their social network, resulting in a decline in their mental health. Individuals in such a state are more likely to request a MAiD outcome. Furthermore, overwhelmed healthcare systems may not adequately address this state, which would normally have prompted a mental health intervention. The future of MAiD is far from settled and careful consideration must be given as new contexts come to light, such as those outlined in this paper.

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

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

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

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

How We Can Improve the Quality of Care for Patients Requesting Medical Assistance in Dying: A Qualitative Study of Health Care Providers

CONTEXT

Since Canada decriminalized medical assistance in dying (MAID) in 2015, clinicians and organizations have developed policies and protocols to implement assisted dying in clinical practice. Five years on, there is little consensus as to what constitutes high-quality care in MAID.

OBJECTIVES

To describe MAID clinicians' perspectives on quality of care in MAID, including challenges, successes, and clinical practice suggestions.

METHODS

We conducted an exploratory, multicenter, and qualitative study at four Canadian centers. Using a semistructured interview guide, we conducted interviews with 20 health care providers. Interviews were transcribed and deidentified before analysis. Adopting a qualitative descriptive approach, we used a thematic analysis to identify primary and secondary themes in the interviews and practice suggestions to improve quality of care to patients who request MAID.

RESULTS

We identified three major themes. 1) Improving access and patient experience: clinicians described struggles in ensuring equitable access to MAID and supporting MAID patients and their families. 2) Supporting providers and sustainability: clinicians described managing MAID workload, remuneration, educational needs, and the emotional impact of participating in assisted dying. 3) Institutional support: descriptions of MAID communication tools and training, use of standardized care pathways, interprofessional collaboration, and human resource planning. Clinicians also described suggestions for clinical practice to improve quality of care.

CONCLUSION

Canadian health care providers described unique challenges in caring for patients who request MAID, along with practices to improve the quality of care.

Facilitators and Barriers to Nurse Practitioners Prescribing Methadone for Opioid Use Disorder in Nova Scotia: A Qualitative Study

Background

Opioid use has escalated dramatically resulting in an increase in deaths. Access to treatment for opioid use disorder (OUD) is poor. The addition of nurse practitioners (NPs) as prescribers of methadone for OUD offers potential for improving access. Little is known about what support NPs will require as they prescribe methadone.

Purpose

This paper identifies facilitators and barriers to NPs prescribing methadone.

Methods

In this qualitative study, in-person and phone semi-structured interviews were conducted with 18 participants. Participants included NPs (n=5), physicians (n=5), and stakeholders including members of professional regulatory bodies and government, academics and other clinicians (n=8). Interviews were recorded, transcribed, and analyzed using thematic analysis and software (NVivo 12.4.0) for data management.

Results

Four themes emerged: 1) Pervasive Barrier of Stigma; 2) Perceived Complexity of Patients Living with OUD; 3) NP Education and Practice Supports and; 4) Health Care Context and NP Role Implementation.

Conclusions

Barriers and facilitators to NP prescribing are similar to those encountered by physicians. Factors unique to NPs include the identification of role clarity as a facilitator and navigation of physician networks as a barrier. Research conducted with current NP methadone prescribers is required to evaluate implementation of this service.

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

AIMS AND OBJECTIVES

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

BACKGROUND

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

DESIGN

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

RESULTS

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

DISCUSSION

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

CONCLUSION

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

RELEVANCE TO CLINICAL PRACTICE

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

The Seismic Shift in End-of-Life Care: Palliative Care Challenges in the Era of Medical Assistance in Dying

Background: Concerns regarding personal, professional, administrative, and institutional implications of medical assistance in dying (MAiD) are of particular interest to palliative and hospice care providers (PHCPs), who may encounter additional moral distress and professional challenges in providing end-of-life (EOL) care in the new legislative and cultural era. Objective: To explore PHCPs' encountered challenges and resource recommendations for caring for patients considering MAiD. Design: Qualitative thematic analysis of audio-recorded semistructured interviews with PHCPs. Setting/Subjects: Multidisciplinary PHCPs in acute, community, residential, and hospice care in Vancouver, Canada, with experience supporting patients who have made MAiD inquiries or requests. Measurements: Interviews were deidentified, transcribed verbatim, and coded by four researchers using a common coding scheme. Key themes were analyzed. Results: Twenty-six PHCP participants included physicians (n = 7), nurses (n = 12), social workers (n = 5), and spiritual health practitioners (n = 2). Average interview length was 52 minutes (range 35-90). Analysis revealed four broad challenges associated with providing EOL care after MAiD legalization: (1) moral ambiguity and provider distress, (2) family distress, (3) interprofessional team conflict, and (4) impact on palliative care. Participants also recommended three types of resources to support clinicians in delivering quality EOL care to patients contemplating MAiD: (1) education and training, (2) pre- and debriefing for team members, and (3) tailored bereavement support. Conclusions: PHCPs encountered multilevel MAiD-related challenges, but noted improvement in organizational policies and coordination. Resources to enhance training, pre- and debriefing, and tailored bereavement may further support PHCPs in providing high-quality EOL care as they navigate the legislative and cultural shifts.

Rethinking Carper's personal knowing for 21st century nursing

In 1978, Barbara Carper named personal knowing as a fundamental way of knowing in our discipline. By that, she meant the discovery of self‐and‐other, arrived at through reflection, synthesis of perceptions and connecting with what is known. Along with empirics, aesthetics and ethics, personal knowing was understood as an essential attribute of nursing knowledge evolution, setting the context for the nurse to become receptively attentive to and engaged within the interpersonal processes of practice. Although much has been done over the 40 years since Carper described these ways of knowing, and we have seen enormous advances in empirics and ethics, and I would argue even in aesthetics (understanding the subtle craft of nursing in action), personal knowing may not have attracted its fair share of critical unpacking. Further, we see increasing evidence of a distortion on how forms of personal knowledge, including beliefs and attitudes, are being taken up within segments of the profession; these include legitimizing idiosyncratic positionings and, most worrisome, challenges to the idea that there are and ought to be fundamental truths within nursing that stand as central to disciplinary knowledge. In this paper, the author reflects on the confusion that a continued uncritical deference to personal knowing may be creating and the evolving interests it seems to serve.

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

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

But it's legal, isn't it? Law and ethics in nursing practice related to medical assistance in dying

In June 2015, the Supreme Court of Canada struck down the Criminal Code's prohibition on assisted death. Just over a year later, the federal government crafted legislation to entrench medical assistance in dying (MAiD), the term used in Canada in place of physician-assisted death. Notably, Canada became the first country to allow nurse practitioners to act as assessors and providers, a result of a strong lobby by the Canadian Nurses Association. However, a legislated approach to assisted death has proven challenging in a number of areas. Although it facilitates a degree of accountability, precision and accessibility, it has also resulted in particular challenges negotiating the diverse perspectives of such a morally contentious act. One of these challenges is the tendency to conflate what is legal and what is moral in a modern liberal constitutionalism that places supreme value on autonomy and choice. Such a conflation tends to render invisible the legal and moral/ethical considerations necessary for nurses and nurse practitioners to remain ethical actors. In this paper, we introduce this conflation and then discuss the process of lawmaking in Canada, including the legalization of MAiD and the contributions of nursing to that legalization. We then engage in a hypothetical dialogue about the legal and moral/ethical implications of MAiD for nursing in Canada. We conclude with an appeal for morally sustainable workspaces that, when implementing MAiD, appropriately balance patient choices and nurses' moral well-being.