Provision Of Medical Assistance In Dying Research Articles

Assisted Dying Bill [HL]: ignorance within the House?

Presently, within the United Kingdom, the House of Lords are engaged with the latest challenge to the blanket ban on any and all forms of assisted suicide. The Assisted Dying Bill [HL], which now resides in the Committee Stage, provides an exemption for medical practitioners assisting patients in self-administering medicine to end their lives. The Bill is identical to the previous Bill introduced by Lord Falconer. In light of developments within other foreign jurisdictions, the similarities and, perhaps more significantly, differences between the legislative pieces provide an interesting comparative discussion. The Canadian Medical Assistance in Dying (MAiD) legislation has been in force since 2016 and has since been amended (March 2021). As Canada is somewhat further down the ‘legal road’ in regulating assisted dying, it may prove a fruitful endeavour to use the Canadian developments to assess and predict the possible trajectory of the Assisted Dying Bill in the UK. Features of the Bill reflect similar provisions that have been adjusted or removed in the Canadian legislation, features that are of significant importance and solemnity in the context of those wishing to access assistance in dying. Such examples include that it necessitates that the patient commit the final act, are expected to die within 6 months, and that there must be a ‘reflection period’. Statistical data reporting in Canada has given valuable insight to the provision of MAiD, including some of the features highlighted. The question becomes ‘should the UK Parliament be paying more attention to the Canadian developments in the context of domestic assisted dying Bills?’ Assisted dying is irrefutably embedded deep within many aspects of society. Whether there exists sufficient differences between the societies of the two jurisdictions will determine if the UK is being unnecessarily ignorant or responsibly contextual.

Social workers’ experiences with medical assistance in dying: Survey findings from Quebec, Canada

ABSTRACT As part of a larger survey, we asked social workers whether they had been involved in medical assistance in dying (MAID) so far. Of the 367 survey participants, 141 reported that they had. These were invited to describe their roles, needs, and sense of competence, focusing on their last MAID experience. Roles were diversified, beginning before and extending beyond the provision of MAID. Nearly 60% needed training on MAID. Perceived competence was lower among those lacking training. Findings point to educational needs that must be addressed to ensure the quality of end-of-life care and the well-being of social workers who engage in MAID.

When Prisoners’ “Right to Die” Goes Online: A Case-Study of Legal and Penal Sensibilities

AbstractPrisoners in Canadian federal penitentiaries can obtain medical assistance in dying (MAiD). This raises questions about the nature and legitimacy of pain and death in incarceration. The authors analyze responses to a Canadian Broadcasting Corporation online news article discussing the provision of MAiD to prisoners. The comments exemplify different sensibilities about the state’s lethality with respect to prisoners. These sensibilities—both legal and penal—draw on an array of cultural referents to orient to prisoners’ deaths generally, but also MAiD specifically. The authors explore how certain referents factor in these legal and penal sensibilities and appear to mediate commenters’ judgements. For example, capital punishment factors significantly in conversations about MAiD for prisoners, as well as imaginations of prisoners’ bodies in pain. As a result, there is a spectacularization of prisoners’ carceral death, despite the humane, “civilized” death MAiD provides, which circumscribes how some commenters imagine the procedure and prisoners’ deaths.

Winging it: a qualitative study of knowledge-acquisition experiences for early adopting providers of medical assistance in dying.

Background:Medical Assistance in Dying (MAID) was legalized in Canada without a designated period for implementation. Providers did not have access to customary alternatives for training and mentorship during the first 1–3 years after legalization.Objective:To report on how doctors prepared for their first provision of MAID in the early period after legalization in Canada.Design:Qualitative research design within an interpretive phenomenological theoretical framework. We asked participants to describe their experiences preparing for first MAID provision. Analysis of transcripts elicited themes regarding training and information desired by early adopters for provision of newly legalized MAID.Participants:Twenty-one early adopting physician-providers in five Canadian provinces were interviewed.Results:Few formal training opportunities were available. Many early-adopting providers learned about the procedure from novel sources using innovative methods. They employed a variety of strategies to meet their needs, including self-training and organizing provider education groups. They acknowledged and reflected on uncertainty and knowledge gained from unexpected experiences and missteps. Key phrases from participants indicated a desire for early training and mentorship.Limitations:This study included only the perspective of physicians who were providers of MAID. It does not address the training needs for all health practitioners who receive requests for assisted death nor report the patient/family experience.Conclusion:The Canadian experience demonstrates the importance of establishing accessible guidance and training opportunities for providers at the outset of implementation of newly legalized assisted dying.

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

ABSTRACT 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.

What\u2019s suffering got to do with it? A qualitative study of suffering in the context of Medical Assistance in Dying (MAID)

BackgroundIntolerable 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.MethodsA 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.ResultsFifty 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.ConclusionsHealthcare 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.

Professional experiences of formal healthcare providers in the provision of medical assistance in dying (MAiD): A scoping review.

This scoping review describes the existing literature which examines the breadth of healthcare providers' (HCP's) experiences with the provision of medical assistance in dying (MAiD). This study employed a scoping review methodology: (1) identify research articles, (2) identify relevant studies, (3) select studies based on inclusion/exclusion criteria, (4) chart the data, and (5) summarize the results. In total, 30 papers were identified pertaining to HCP's experiences of providing MAiD. Fifty-three percent of the papers were from Europe (n = 16) and 40% of studies were from the USA or Canada (n = 12). The most common participant populations were physicians (n = 17) and nurses (n = 12). This scoping review found that HCPs experienced a variety of emotional responses to providing or providing support to MAiD. Some HCPs experienced positive emotions through helping patients at the end of the patient's life. Still other HCPs experienced very intense and negative emotions such as immense internal moral conflict. HCPs from various professions were involved in various aspects of MAiD provision such as responding to initial requests for MAiD, supporting patients and families, nursing support during MAiD, and the administration of medications to end of life. This review consolidates many of the experiences of HCPs in relation to the provision of MAiD. Specifically, this review elucidates many of the emotions that HCPs experience through participation in MAiD. In addition to describing the emotional experiences, this review highlights some of the roles that HCPs participate in with relation to MAiD. Finally, this review accentuates the importance of team supports and self-care for all team members in the provision of MAiD regardless of their degree of involvement.

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.

Why Death Need Not Be "Reasonably Foreseeable"-The Proposed Legislative Response to Truchon and Gladu v Attorney General (Canada) and Attorney General (Quebec) [2019] QCCS 3792.

Medical Assistance in Dying (MAID) has become an inescapable reality in Canada since the Supreme Court of Canada (SCC) declared in Carter v Canada (Attorney General) ([2015] 1 S.C.R. 331) (Carter) that the blanket prohibition on physician assisted dying was unconstitutional. Instead of prescribing the regulatory criteria to control the provision of MAID, the SCC invited the respective federal and provincial governments to establish the legislative framework (Carter, [127]).

Factors predicting the risk of loss of decisional capacity for medical assistance in dying: a retrospective database review.

Bill C-14, the legislation that legalized medical assistance in dying (MAiD) in Canada in 2016, outlines eligibility criteria and includes both a mandated 10-day reflection period and a requirement that the patient have capacity to consent at the time MAiD is provided. We examined clinical factors associated with shortened reflection periods or loss of capacity before provision of MAiD. This retrospective database review involved patients who requested MAiD at a tertiary care hospital in Toronto, Canada, between June 2016 and April 2019. We used logistic regression analyses to examine the association between the combined outcome of unanticipated loss of decisional capacity, shortening of the reflection period or death and the clinical risk factors of interest (age, sex, location of MAiD request [inpatient v. outpatient], score on palliative performance scale [PPS] and diagnosis [cancer v. noncancer]). We generated receiver operating characteristic curves to identify the PPS score (encompassing 5 functional domains: ambulation, activity level, self-care, intake and level of consciousness) that best predicted loss of capacity, shortening of the reflection period or death. In total, 155 patients requested assessment for MAiD, and 136 of these were included in the statistical analyses. For 68 patients, the reflection period was not shortened; the other 68 patients lost capacity, died or required shortening of the reflection period. In contrast to the results for age, sex, location of request and diagnosis, the PPS score was associated with loss of capacity or shortening of the reflection period (odds ratio 4.63, 95% confidence interval 2.87-8.23, per 10-point decrease in PPS score). PPS scores less than or equal to 40% balanced sensitivity, specificity and negative predictive value while emphasizing sensitivity to prevent false negative errors. The PPS score at the time of MAiD request was strongly associated with loss of capacity or shortening of the reflection period, with lower scores incrementally increasing the risk of these outcomes. For patients with a PPS score of 40% or below, close monitoring is warranted, potentially with plans made to allow rapid provision of MAiD should their clinical condition deteriorate.

Conscientious refusal to provide medically assisted dying

Medical assistance in dying (MAiD) became legal in Canada in June 2016. Since that time, many health-care practitioners and health-care institutions have undertaken to provide it, and thousands of Canadians have taken advantage of it. At the same time, a significant number of both practitioners and institutions have refused provision of MAiD for various reasons, including conscience-based objections to it. In this article, I argue that refusal by practitioners could, and should, be tolerated but only where it could be accommodated in practice groups without unduly burdening willing providers or adversely affecting patient access. My conclusion about refusal by institutions is less compromising. In this case, the cost to vulnerable patients of MAiD being delayed or denied is much greater and the burdens of conscience (if we may call them that) to institutions are insignificant. Since it cannot be accommodated without seriously impairing both patient access and patient well-being, refusal by publicly funded health-care institutions to offer MAiD must be completely disallowed.

Medical assistance in dying for the psychiatrically ill reply to Buturovic

In a recent Response published in the Journal of Medical Ethics ,1 Buturovic provides two criticisms of my argument in ‘Is the exclusion of psychiatric patients from access to physician-assisted...

Conscientious Refusal to Provide Medically-Assisted Dying

Medical assistance in dying (MAiD) became legal in Canada in June 2016. Since that time many health care practitioners and health care institutions have undertaken to provide it, and thousands of Canadians have taken advantage of it. At the same time, a significant number of both practitioners and institutions have refused provision of MAiD for various reasons, including conscience-based objections to it. In this paper I argue that refusal by practitioners could, and should, be tolerated where it could be accommodated without adversely affecting patient access, but not otherwise. My conclusion about refusal by institutions is less compromising. In this case the cost to vulnerable patients of MAiD being delayed or denied is much greater and the burdens of conscience (if we may call them that) to institutions are insignificant. Since it cannot be accommodated without seriously impairing both patient access and patient well-being, refusal by publicly-funded health care institutions to offer MAiD must be completely disallowed.

MEDICAL ASSISTANCE IN DYING (MAID)

Medical Assistance in Dying (MAID) is a legal federal framework for medical practitioners to assist in the cessation of life upon request from eligible patients who seek assisted death in order to die peacefully and with dignity. MAID’s ‘mentally competent’ eligibility criteria currently create confusion for social workers because they provide little guidance on how to best implement the desired practices intended to support the aims of MAID. Secondly, current criteria pose challenges for vulnerable populations, particularly patients with amyotrophic lateral sclerosis (ALS). ALS patients who are deemed mentally incapable are denied access to MAID, suffering in pain every day until they die. Canada’s MAID policy infringes on their autonomy, and removes their choice to die with dignity. This injustice calls for further reconsideration of the ways MAID can be reformed to serve dying Canadians who are falling through the cracks of MAID. Policy recommendations include inclusion of advanced directives and substitute decision makers. Due to this unequal access in health care services, this concern constitutes a social work issue. Recommendations for social work include increasing competency, and advocacy regarding the provision of MAID.

Medical Assistance in Dying (MAiD): Ten Things Leaders Need to Know.

The provision of MAiD will be in flux for a few years, as legislative challenges are underway. This article addresses what leaders need to know and do to support nurses today and in the future regarding care of patients choosing MAiD. Drawing on complexity leadership theory and research into nurses' experiences in caring for persons choosing MAiD, we share 10 simple yet foundational things a leader must know. Underpinning our key messages are current evidence and familiar nursing concepts such as end-of-life care, death trajectories, conscientious objection, scope of practice, ethics, sense-making and care cultures. These key messages are embedded in a framework of leadership practices where attention to inter-relationships, emergence and innovation are highlighted. They provide nurse leaders with concrete actions to inspire a team dynamic for creating inclusive cultures of quality care. Leadership is needed across healthcare settings where MAiD is being enacted.

The spectrum of end of life care: an argument for access to medical assistance in dying for vulnerable populations.

Medical assistance in dying (MAiD) was legalized by the Supreme Court of Canada in June 2016 and became a legal, viable end of life care (EOLC) option for Canadians with irremediable illness and suffering. Much attention has been paid to the balance between physicians' willingness to provide MAiD and patients' legal right to request medically assisted death in certain circumstances. In contrast, very little attention has been paid to the challenge of making MAiD accessible to vulnerable populations. The purpose of this paper was to examine the extant literature and resources that are available on the provision of MAiD in Canada. We found that the provision of EOLC in Canada offers insufficient access to palliative and EOLC options for Canadians and that vulnerable Canadians experience disproportional barriers to accessing these already limited resources. Consequently, we argue that palliative care, hospice care and MAiD must be considered a spectrum of EOLC that is inclusive and accessible to all Canadians. We conclude by imploring Canadian healthcare professionals, policy makers and legislators to consider MAiD as a viable EOLC option for all Canadians.

Analysis of the Medical Assistance in Dying Cases in Ontario: Understanding the Patient Demographics of Case Uptake in Ontario since the Royal Assent and Amendments of Bill C-14 in Canada

On June 17, 2016, the Canadian government legalized medical assistance in dying (MAID) across the country by giving Royal Assent to Bill C-14. This Act made amendments to the Criminal Code and other Acts relating to MAID, allowing physicians and nurse practitioners to offer clinician-administered and self-administered MAID in conjunction with pharmacists being able to dispense the necessary medications. The eligibility criteria for MAID indicates that the individual 1) must be a recipient of publicly funded health services in Canada, 2) be at least 18 years of age, 3) be capable of health-related decision-making, and 4) has a grievous and irremediable medical condition. Because this is a new practice in Canadian health care, there are no published Canadian statistics on MAID cases to date, and this paper constitutes the first analysis of MAID cases in both the province of Ontario and Canada. Internationally, there are only a few jurisdictions with similar legislation already in place (US, the Netherlands, Belgium, Luxembourg, Switzerland, Columbia, Japan, and the United Kingdom). The published statistics on MAID cases from these jurisdictions were reviewed and used to establish the current global practices and demographics of MAID and will provide useful comparisons for Canada. This analysis will 1) outline the Canadian legislative approach to MAID, 2) provide an understanding of which patient populations in Ontario are using MAID and under what circumstances, and 3) determine if patterns exist between the internationally published MAID patient demographics and the Canadian MAID data. Selected patient demographics of the first 100 MAID cases in Ontario were reviewed and analyzed using anonymized data obtained from the Office of the Chief Coroner for Ontario so that an insight into the provision of MAID in Ontario could be obtained. Demographic factors such as age, sex, the primary medical diagnosis that prompted the request for MAID, the patient rationale for making a MAID request, the place where MAID was administered, the nature of MAID drug regimen used, and the status/specialty of medical personnel who administered the MAID drug regimen were analyzed. The analysis revealed that the majority of the first 100 MAID recipients were older adults (only 5.2% of patients were aged 35-54 years, with no younger adults between ages 18-34 years) who were afflicted with cancer (64%) and had opted for clinician-administered MAID (99%) that had been delivered in either a hospital (38.8%) or private residence (44.9%). Although the cohort was small, these Ontario MAID demographics reflect similar observations as those published internationally, but further analysis of both larger and annual case uptake in both Ontario and Canada will be conducted as the number of cases increases.