European nurses' attitudes towards assisted death: A scoping review.

Death with Dignity in Canada

Editorial: A time to live, a time to die? An exploration of the arguments surrounding the legalisation of assisted suicide

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.

BackgroundThe Supreme Court of Canada removed the prohibition on physicians assisting in patients dying on 6 February 2015. Bill C-14, legalising medical assistance in dying (MAID) in Canada, was subsequently...

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

Introduction: The expansion of medical assistance in dying (MAiD) in Canada to include, as of Mar. 17, 2027, mental illness as a sole underlying medical condition (MI-SUMC) raises significant clinical, legal, and ethical concerns, particularly for Veterans, who are disproportionately affected by difficult-to-treat psychiatric conditions. Structural vulnerabilities, including poverty, discrimination, gender-based disparities, and poor access to care, compound psychiatric suffering and increase the risk of premature death among marginalized groups. Methods: The authors conducted a comprehensive review of clinical, legal, and ethical literature, including expert reports, case law, and systematic reviews. Key areas of analysis include terminology regarding difficult-to-treat conditions, limitations of current capacity assessments, structural vulnerability, and ethical tensions between suicide prevention and MAiD for MI-SUMC. Results: There is no consistent definition of difficult-to-treat conditions, with over 150 existing for major depressive disorder alone. Prognoses remain highly variable, weakening claims of irremediability. Current capacity assessments often overlook trauma, emotional states, and systemic barriers, introducing bias. Suicidality, a common symptom of psychiatric illness, complicates distinctions between autonomous MAiD requests and crisis responses. Last, evidence from jurisdictions like Belgium and the Netherlands demonstrates that structurally marginalized individuals are over-represented in psychiatric MAiD, raising concerns of systemic coercion. Discussion: Given the unresolved uncertainties around irremediability, suicidality, and access to care, a precautionary approach is warranted. Without equitable access to advanced, neuroscientifically informed treatments, some may request MAiD because of lack of alternatives. Safeguards such as longitudinal monitoring, inter-blinded assessments, and expanded access to care are essential to protect vulnerable groups, especially Veterans.

In June 2016, Bill C-14 or Medical Assistance in Dying legislation became law in Canada. With this law came changes to nurses' (ie, nurse practitioner, registered nurse, registered practical nurse) scopes of practice, roles, and responsibilities. While federal law, regulatory, and organizational policies are developed to inform nurses about the practice of medical assistance in dying, there is little evidence examining how nurses' roles and responsibilities are enacted in practice. Therefore, a scoping review was conducted to synthesize the evidence on nurses' roles and responsibilities in relation to medical assistance in dying and to identify gaps in the literature. A secondary aim was to identify organizational supports for nurses to effectively and ethically engage in medical assistance in dying. Using a recognized and rigorous scoping review methodology, the findings from 24 research studies were synthesized in this article. The analysis highlights the importance of effective health care professional engagement with the individual in the decision-making process and of the need to educate, support, and include nurses in providing medical assistance in dying. Overall, the current research on medical assistance in dying is limited in Canada, and more attention is needed on the role of the nurse.

Euthanasia and physician assisted suicide (PAS) are two controversial topics in neurosurgical practice. Personal attitudes and opinions on these important issues may vary between professionals, and may also depend on their location since current legislation differs between European countries. As these issues may have significant impact on clinical practice, the goal of the present study was to survey the opinions of neurosurgical residents and young neurosurgeons across Europe with respect to euthanasia and physician assisted suicide. We performed a survey among the participants of the European Association of Neurosurgical Societies (EANS) training courses (2011-2012), asking residents and young neurosurgeons nine questions on euthanasia and PAS. For the analysis of this survey, we divided all 295 participants into four European regions (North, South, East, West). We found that even though most residents are aware of regulations about euthanasia or PAS in their country or hospital, a substantial number were not aware of the regulations. We observed no significant differences in terms of their opinions on euthanasia and PAS among the four European regions. While most are actually in favor of euthanasia or PAS, if legally allowed, under appropriate circumstances, very few neurosurgeons would be willing to actively participate in these end-of-life practices. The results of this first survey on neurosurgical residents' attitudes towards euthanasia and PAS show that a significant number of residents is not familiar with national and/or local regulations regarding euthanasia and PAS. If legally allowed, most residents would be in favor of euthanasia and PAS, but only a minority would be willing to actively participate in these practices. We did not observe a difference in stances on euthanasia and PAS among residents from different regions in Europe.

Following the historic Canadian legislation on medical assistance in dying (MAiD) in 2016, many implementation challenges and ethical quandaries have formed the focus of further scholarly investigation and policy revisions. Of these, conscientious objections held by some healthcare institutions have involved relatively less scrutiny, despite indicating possible hurdles to the universal availability of MAiD services in Canada. In this paper, we contemplate potential accessibility concerns that pertain specifically to service access, with the hope to trigger further systematic research and policy analysis on this frequently overlooked aspect of MAiD implementation. We organize our discussion using two important health access frameworks: Levesque and colleagues' Conceptual Framework for Access to Health and the Provisional Framework for MAiD System Information Needs (Canadian Institute for Health Information). Our discussion is organized along five framework dimensions through which institutional non-participation may generate or exacerbate inequities in MAiD utilization. Considerable overlaps are revealed across framework domains, indicating the complexity of the problem and the need for further investigation. Conscientious dissensions on the part of healthcare institutions form a likely barrier to ethical, equitable, and patient-oriented MAiD service provision. Comprehensive, systematic evidence is urgently needed to understand the nature and scope of resulting impacts. We urge Canadian healthcare professionals, policymakers, ethicists, and legislators to attend to this crucial issue in future research and in policy discussions.

Medical assistance in dying (MAiD), encompassing euthanasia and assisted suicide, has expanded from its original focus on terminal somatic illness to include, in some jurisdictions, individuals with psychiatric disorders. This shift has raised major ethical, legal, and clinical concerns. While proponents argue for respecting autonomy and recognizing the severity of psychological suffering, opponents highlight diagnostic uncertainty, fluctuating decision-making capacity, and the risk of extending MAiD to vulnerable individuals. This narrative review provides a comprehensive overview of the legal frameworks, ethical debates, and clinical patterns surrounding assisted suicide and euthanasia for psychiatric disorders across Europe. It further examines expert concerns, the characteristics of patients requesting MAiD, and unresolved challenges related to competence, irremediability, and the potential overlap with suicidal behavior. Across Europe, MAiD for psychiatric disorders remains ethically contested and inconsistently regulated. The growing number of requests underscores the need for clearer diagnostic standards, structured safeguards, and parallel treatment pathways to ensure that decisions are autonomous, informed, and not driven by potentially reversible psychopathology. The current landscape of MAiD for psychiatric disorders in Europe is marked by legal variability, ethical tension, and clinical uncertainty. Clarifying assessment standards, strengthening safeguards, and improving access to evidence-based treatments are essential to ensure that decisions are both ethically sound and clinically justified. Ongoing debate highlights the need for careful, evolving regulation in this highly sensitive area.

Background: In several European countries, medical assistance in dying (MAID) is no longer confined to persons with a terminal prognosis but is also available to those suffering from persistent and unbearable mental illness. To date, scholarly discourse on MAID in this population has been dominated by issues such as decision-making capacity, uncertainty as to when a disease is incurable, stigmatization, isolation, and loneliness. However, the issue of perceived burdensomeness has received little attention.Objective: The study explores the possible impact of perceived burdensomeness on requests for MAID among persons with severe and persistent mental illness (SPMI).Method: Using the method of ethical argumentation, we discuss the issue of access to MAID for persons with SPMI and perceived burdensomeness.Conclusion: Perceived burdensomeness may be a contributing factor in the wish for hastened death among persons with SPMI. MAID is ethically unsupportable if SPMI causes the individual to make an unrealistic assessment of burdensomeness, indicating a lack of decision-making capacity in the context of that request. However, the possibility that some individuals with SPMI may perceive burdensomeness does not mean that they should be routinely excluded from MAID. For SPMI patients with intact decision-making capacity who feel their life is not worth living, perceived burdensomeness as a component of this intolerable suffering is not a sufficient reason to deny access to MAID.

BackgroundMedical 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.MethodsA 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.ResultsBetween 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.ConclusionsThe 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.

Physician-assisted death (PAD) began as a question of constitutional rights, framed in the public’s consciousness by several high-profile court battles as the “right-to-die.” Over the last twenty years PAD has been dramatically transformed from the right to die to an issue expressed as “death with dignity” that includes broad considerations of healthcare, dignity, privacy and decisional autonomy. By contrast, the abortion right has experienced the opposite legal trajectory and considerably less dynamic range. Originally inspired by broad feminist ideals as one aspect of a larger call for equality, over the last forty years it has been significantly narrowed to an almost exclusive focus on “choice.” In case law and legislation, the issue continues to be framed as a constitutional right to decide to terminate a pregnancy and has been less successful in engaging broader questions of reproductive justice such as dignity, equality, autonomy and healthcare. This article considers why these two issues have experienced such dramatically different legal outcomes despite the fact that they share a legal lineage and engage similar moral and ethical tensions. I conclude that a significant part of the answer lies in the fact that abortion was granted status as a constitutional right, and PAD was not. I use the comparison with PAD as a vehicle for exploring the limitation that the constitutional rights framework has imposed on the abortion right and to consider ways to apply the successes of PAD to similarly broaden the framing of the abortion right.

This position paper explores the complex issue of Physician-Assisted Suicide (PAS) in the context of Neurology. It discusses the legal, ethical, and clinical challenges surrounding PAS, including the role of neurologists in assessing eligibility based on prognosis, decision-making capacity, and functional status. The paper outlines Italy’s legal framework regarding PAS, following a landmark 2019 Constitutional Court ruling, which permits PAS under strict conditions for patients suffering from incurable illnesses. It also compares PAS regulations in other European and non-European countries. The Italian Society of Neurology (SIN) emphasizes the importance of respecting patient autonomy while advocating for comprehensive palliative care (PC). The SIN’s position is that PAS should be legalized under specific circumstances but insists on ensuring equitable access to PC services before considering PAS. Additionally, the SIN supports the training of neurologists in palliative and end-of-life care, underlining the need for careful monitoring and regulation of PAS practices to prevent potential ethical and legal abuses.

Assisted Suicide in Switzerland: The 10-Year Experience of a Palliative Care Unit Medical Director and Ethic Committee Member (FR412)