The Impact of Institutional Abstinence from Medical Assistance in Dying (MAiD): A Qualitative Study Protocol For Understanding Patient Transfer Journeys (Preprint)

Ethical Debate ◽

Vulnerable Patients ◽

The Press ◽

Alternative Routes ◽

Key Resources ◽

UNSTRUCTURED Many healthcare institutions in Canada currently decline to provide medical assistance in dying (MAID) on-site for religious or moral reasons. If patients receiving medical care at such institutions request MAiD, they need to be transferred elsewhere in order to access this important medical service and Charter-protected legal right. The process places additional burdens—in terms of seeking information and support, navigating the health system, and communicating with health professionals—on vulnerable patients who are already battling grievous illness and psychological distress. While anecdotes relating to the issue occasionally appear in the press, there is very little systematic evidence on the experiences of patients and families who make this critical transition in care. This study aims to fill this vital knowledge gap by mapping the MAiD access trajectories of patients and families at MAiD-abstaining institutions. Through a combination of textual analysis (media sources and institutional grey literature) and in-depth interviews (with patients, families, policymakers, and health professionals), this project will generate evidence on how patients and families interact with healthcare institutions and professionals; where they seek information; who they turn to for support and decision-making; what alternative routes they choose when faced with barriers; and where key resources to support their transfer journeys are located. Utilizing the Patient Engagement Framework suggested by the Strategy for Patient-Oriented Research (SPOR), this study will involve patients and families—across all stages of its research design—for: (i) informing the socio-ethical debate on institutional MAiD-abstinence; (ii) identifying gaps in MAiD service delivery, and (iii) making policy recommendations for equitable access to MAiD.

P009: Medical assistance in dying – a survey of Canadian emergency physicians

CJEM ◽

10.1017/cem.2019.200 ◽

2019 ◽

Vol 21 (S1) ◽

pp. S66

Author(s):

F. Bakewell

Keyword(s):

Emergency Medicine ◽

Terminal Illness ◽

Free Form ◽

Medical Attention ◽

Emergency Physicians ◽

Medical Assistance ◽

Electronic Survey ◽

Self Harm ◽

Introduction: There have been 3714 medically assisted deaths recorded in Canada so far, with more than half of those deaths occurring outside the hospital – whether this has had any impact on emergency medicine has not yet been documented. This survey sought to find out Canadian emergency physicians’ (EPs) attitudes and experiences with medical assistance in dying (MAID). Methods: An electronic survey was distributed to CAEP members using a modified Dillman technique. The primary outcome was defined as the proportion of EPs in favour of MAID. Secondary outcomes included experience with suicide in the setting of terminal illness, their experience and opinion on referring patients for MAID from the ED, their experience with complications of MAID, and their response to hypothetical cases of complications from MAID. Nominal variables were analyzed and reported as percentages for each relevant answer. Answers submitted as free-form text were coded into themes by the author and reported based on these themes. Results: There were 303 completed surveys. EPs were largely in support of MAID (80.5%), and would be willing to refer patients for assessment from the ED (83.2%), however fewer (58.3%) knew how to do so. 37.1% of EPs had been asked for a referral for MAID assessment, but only 12.5% had made a referral. While only 1% of EPs reported having seen patients present with complications from MAID (failed IVs in the community), 5.0% had seen patients present with suicide or self-harm attempts after being told they were ineligible for MAID by another provider. Conclusion: This is the first study to examine the impact of MAID on emergency medicine in Canada, and it demonstrates that patients are both requesting referrals through the ED and, in rare cases, requiring medical attention for complications. This has implications for both increasing awareness of MAID referral processes for EPs, as well as for the prevention and treatment of complications of MAID in the community.

Medical assistance in dying: implications for health systems from a scoping review of the literature

Journal of Health Services Research & Policy ◽

10.1177/1355819619834962 ◽

2019 ◽

Vol 24 (3) ◽

pp. 207-216 ◽

Cited By ~ 2

Author(s):

Jamie K. Fujioka ◽

Raza M. Mirza ◽

Christopher A. Klinger ◽

Lynn P. McDonald

Keyword(s):

Health Systems ◽

Scoping Review ◽

Grey Literature ◽

Models Of Care ◽

Careful Examination ◽

Multidisciplinary Teams ◽

Medical Assistance ◽

Implementation Barriers ◽

Regulatory Oversight ◽

Medical Assistance In Dying

Objective Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems. Methods We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers. Results The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail. Conclusion Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.

Medical assistance in dying: A gendered issue in Canada?

Spectrum ◽

10.29173/spectrum93 ◽

2020 ◽

Author(s):

Freya Hammond-Thrasher

Keyword(s):

Human Life ◽

Grey Literature ◽

Gender Issues ◽

Personal Choice ◽

Medical Assistance ◽

Liberal Democratic ◽

People With Mental Illness ◽

Women's Lives ◽

Controversial Topic

Medical assistance in dying (MAiD) remains a controversial topic in Canada despite its legalization in 2015. Opponents of MAiD legislation often cite ‘pro-life’ or ‘pro-choice’ arguments which emphasize the value of human life. While all eligible adults are currently able to request MAiD, scholars, citizens, and religious organizations have expressed concerns that women, as a marginalized group, are at risk to request assisted dying due to gendered circumstances rather than personal choice. My research investigates the claim that women’s lives are threatened by MAiD legislation and analyzes the ways in which MAiD is a gendered issue. Drawing from seventeen academic, government, and grey literature sources, I identify and challenge three key discursive categories used to present women as vulnerable under MAiD legislation. I argue that opponents of MAiD legislation co-opt feminist discourses to make normative claims which resonate with the values of individualism in Canadian liberal democratic society. In doing so, opponents of MAiD reproduce the same gender issues they claim to oppose and risk endangering women’s access to MAiD in Canada. I conclude with recommendations relevant to the next stage of MAiD legislation in Canada, which will debate whether other populations considered to be vulnerable, including mature minors and people with mental illness, will have access to MAiD.

Medically Assisted Dying in Canada: “Beautiful Death” Is Transforming Nurses’ Experiences of Suffering

Canadian Journal of Nursing Research ◽

10.1177/0844562119856234 ◽

2019 ◽

pp. 084456211985623 ◽

Cited By ~ 3

Author(s):

Anne Bruce ◽

Rosanne Beuthin

Keyword(s):

End Of Life ◽

Secondary Analysis ◽

Emotional Impact ◽

Assisted Dying ◽

Medical Assistance ◽

Narrative Study ◽

Qualitative Secondary Analysis ◽

BackgroundNurses witness pain and distress up close and consequently experience their own suffering. A narrative study of Canadian nurses’ participating in medical assistance in dying found nurses’ previous witnessing of unresolved end-of-life suffering has shaped their acceptance of medical assistance in dying. Little is known about the impact of participating in medically assisted dying on nurses’ suffering.PurposeTo explore how nurses’ overall experience of suffering is shaped by participating in medical assistance in dying.MethodsQualitative secondary analysis using narrative inquiry and thematic analysis.ResultsNurses’ narratives are chronologically organized addressing experiences of suffering before medical assistance in dying was a legal option and after its implementation. An overarching narrative before the availability of medical assistance in dying is (1) a culture of nurses’ taken-for-granted suffering: feeling terrible. After medical assistance in dying, two key narratives describe (2) transformational feelings of a beautiful death and (3) residual discomfort. Nurses found their suffering transformed when participating in medical assistance in dying; end-of-life care was satisfying and gratifying. And yet, unanswered questions due to worries of becoming desensitized and ongoing deeper questioning remain.ConclusionsParticipating in medical assistance in dying has positively impacted nurses and starkly contrasts their previous experiences caring for those with unbearable suffering. Further research is needed to explore becoming desensitized and long-term emotional impact for nurses.

Mental illness and medical aid in dying

University of Western Ontario Medical Journal ◽

10.5206/uwomj.v88i2.7592 ◽

2020 ◽

Author(s):

Gali Katznelson ◽

Jacek Orzylowski

Keyword(s):

Mental Health ◽

Health Care ◽

Mental Disorder ◽

Mental Health Care ◽

Mental Health Professionals ◽

Health Professionals ◽

Medical Condition ◽

Medical Assistance ◽

Aid In Dying

A 2017 survey of 529 psychiatrists in Canada found that while 72% of psychiatrists supported medical assistance in dying (MAID) in some cases, only 29.4% supported MAID solely on the basis of mental disorders. Understanding and addressing the concerns of mental health professionals will be crucial in deciding whether and how to expand MAID solely for a mental disorder in Canada. The report, “The State of Knowledge on Medical Assistance in Dying Where a Mental Disorder Is the Sole Underlying Medical Condition,” authored by The Council of Canadian Academies, highlights some concerns that mental health professionals might harbour. These include potentially feeling that there is a conflict between providing MAID and their duties as mental health care workers, the subjectivity of the current law, and Canada’s inequitable mental health care system.

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

Qualitative Health Research ◽

10.1177/10497323211027130 ◽

2021 ◽

pp. 104973232110271

Author(s):

Janine Brown ◽

Donna Goodridge ◽

Lilian Thorpe ◽

Alexander Crizzle

Keyword(s):

Nurse Practitioners ◽

Current Practice ◽

Social Contact ◽

Time Factors ◽

Interpretive Description ◽

Medical Assistance ◽

Factors Influencing ◽

Exogenous Factors ◽

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.

The Impact of Providing Medical Assistance in Dying (MAiD) on Providers

Journal of Pain and Symptom Management ◽

10.1016/j.jpainsymman.2018.10.312 ◽

2018 ◽

Vol 56 (6) ◽

pp. e89 ◽

Cited By ~ 1

Author(s):

Margaret McKee ◽

Megan Sellick

Keyword(s):

Medical Assistance ◽

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

BMJ Open ◽

10.1136/bmjopen-2021-055789 ◽

2021 ◽

Vol 11 (12) ◽

pp. e055789

Author(s):

Gilla K Shapiro ◽

Eryn Tong ◽

Rinat Nissim ◽

Camilla Zimmermann ◽

Sara Allin ◽

...

Keyword(s):

Palliative Care ◽

Qualitative Study ◽

Policy Development ◽

Qualitative Interview ◽

Medical Assistance ◽

Key Stakeholders ◽

The Government ◽

The Impact ◽

The Relationship

IntroductionCanadians have had legal access to medical assistance in dying (MAiD) since 2016. However, despite substantial overlap in populations who request MAiD and who require palliative care (PC) services, policies and recommended practices regarding the optimal relationship between MAiD and PC services are not well developed. Multiple models are possible, including autonomous delivery of these services and formal or informal coordination, collaboration or integration. However, it is not clear which of these approaches are most appropriate, feasible or acceptable in different Canadian health settings in the context of the COVID-19 pandemic and in the post-pandemic period. The aim of this qualitative study is to understand the attitudes and opinions of key stakeholders from the government, health system, patient groups and academia in Canada regarding the optimal relationship between MAiD and PC services.Methods and analysisA qualitative, purposeful sampling approach will elicit stakeholder feedback of 25–30 participants using semistructured interviews. Stakeholders with expertise and engagement in MAiD or PC who hold leadership positions in their respective organisations across Canada will be invited to provide their perspectives on the relationship between MAiD and PC; capacity-building needs; policy development opportunities; and the impact of the COVID-19 pandemic on the relationship between MAiD and PC services. Transcripts will be analysed using content analysis. A framework for integrated health services will be used to assess the impact of integrating services on multiple levels.Ethics and disseminationThis study has received ethical approval from the University Health Network Research Ethics Board (No 19-5518; Toronto, Canada). All participants will be required to provide informed electronic consent before a qualitative interview is scheduled, and to provide verbal consent prior to the start of the qualitative interview. Findings from this study could inform healthcare policy, the delivery of MAiD and PC, and enhance the understanding of the multilevel factors relevant for the delivery of these services. Findings will be disseminated in conferences and peer-reviewed publications.

A National Survey of Canadian Psychiatrists’ Attitudes toward Medical Assistance in Death

The Canadian Journal of Psychiatry ◽

10.1177/0706743717711174 ◽

2017 ◽

Vol 62 (11) ◽

pp. 787-794 ◽

Cited By ~ 7

Author(s):

Skye Rousseau ◽

Sarah Turner ◽

Harvey Max Chochinov ◽

Murray W. Enns ◽

Jitender Sareen

Keyword(s):

Mental Illness ◽

Online Survey ◽

Response Rate ◽

Cross Sectional Study ◽

Sectional Study ◽

Medical Assistance ◽

Cross Sectional ◽

Psychological Suffering ◽

Vulnerable Patients

Background: Bill C-14 allows for medical assistance in dying (MAID) for patients who have intolerable physical or psychological suffering that occurs in the context of a reasonably foreseeable death. In Canada, psychiatrist support for MAID on the basis of mental illness and beliefs influencing level of support are unknown. The objectives of this research were to 1) determine if psychiatrists are supportive of MAID under certain conditions and on the basis of mental illness and 2) determine what factors are related to psychiatrist support for MAID on the basis of mental illness. Methods: This cross-sectional study was conducted among 528 psychiatrists in Canada using an online survey platform (February 19 to March 11, 2016). Results: The response rate was 20.9% ( n = 528). Most psychiatrists supported the legalisation of MAID in some circumstances (72%); however, only 29.4% supported MAID on the basis of mental illness. Factors correlating with decreased support for MAID for mental illness were the belief that MAID for mental illness would change the psychiatrists’ commitment to their patients through enduring suffering, having a personal faith, and having had past patients who would have received MAID for mental illness were it legal but instead went on to recover. Interpretation: This study found that most psychiatrists do not support the legalisation of MAID for mental illness, despite being quite supportive of MAID in general. Objections seemed to be based upon concern for vulnerable patients, personal moral objections, and concern for the effect it would have on the therapeutic alliance.

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

Palliative Medicine ◽

10.1177/0269216320968517 ◽

2020 ◽

pp. 026921632096851

Author(s):

Jean Jacob Mathews ◽

David Hausner ◽

Jonathan Avery ◽

Breffni Hannon ◽

Camilla Zimmermann ◽

...

Keyword(s):

Palliative Care ◽

Ethical Decision Making ◽

Care Delivery ◽

Symptom Control ◽

Care Practice ◽

Care Providers ◽

Medical Assistance ◽

Assisted Death ◽

Background: Medical Assistance in Dying comprises interventions that can be provided by medical practitioners to cause death of a person at their request if they meet predefined criteria. In June 2016, Medical Assistance in Dying became legal in Canada, sparking intense debate in the palliative care community. Aim: This study aims to explore the experience of frontline palliative care providers about the impact of Medical Assistance in Dying on palliative care practice. Design: Qualitative descriptive design using semi-structured interviews and thematic analysis Settings/participants: We interviewed palliative care physicians and nurses who practiced in settings where patients could access Medical Assistance in Dying for at least 6 months before and after its legalization. Purposeful sampling was used to recruit participants with diverse personal views and experiences with assisted death. Conceptual saturation was achieved after interviewing 23 palliative care providers (13 physicians and 10 nurses) in Southern Ontario. Results: Themes identified included a new dying experience with assisted death; challenges with symptom control; challenges with communication; impact on palliative care providers personally and on their relationships with patients; and consumption of palliative care resources to support assisted death. Conclusion: Medical Assistance in Dying has had a profound impact on palliative care providers and their practice. Communication training with access to resources for ethical decision-making and a review of legislation may help address new challenges. Further research is needed to understand palliative care provider distress around Medical Assistance in Dying, and additional resources are necessary to support palliative care delivery.