Medical Assistance in Dying – One Year Later

In the year since Bill C-14 passed, legalizing Medical Assistance in Dying (MAID), over 1300 Canadians have exercised their right to die[1] [2]. Depending on your feelings about this topic, this may feel like a large or small number. It terms of total deaths, MAiD accounts for approximately 0.6% of the total number of deaths in Canada.

Country

Percentage of total deaths

Netherlands (2015)3

3.75%

Belgium (2015)[3]

1.83%

Canada (2016-2017)

0.6%

Oregon (2016) [4]

0.37%

Compelling accounts of people who have requested and received MAiD are freely available online, and in the popular media for people wishing to learn what the process is like, and how family might be affected by the dying person’s decision to end their life. Two examples of such stories are:

Where Do You Stand on Medical Assistance in Dying/Physician Assisted Dying?

Excerpted from Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse, 2016

What is currently missing from the commentary is information about how nurses and other health care professionals (HCPs) are deciding whether to support MAiD, participate in MAiD or oppose MAiD. Dr. David Wright, from the University of Ottawa, developed a series of questions to assist HCPs in discovering how they feel about MAiD. This series of questions are included in the Nurse’s text to specifically assist nurses to understand their own response to MAiD. At the end of the series of question is feedback that can assist and guide the next steps for health care professionals.

Featured below is the first of these questions . Respondents use the horizontal colour thermometer to identify the intensity of their If you are struggling to determine your position about MAiD, you may want to consider using these questions.

 

Accessing Education to Make an Informed Choice About MAiD

Fortunately, there are many webinars and online courses that will help new and established health care professionals learn about MAiD, the rights and obligations of health care professionals, and to make an informed decision about their desired level of participation. Examples of education currently available are:

  • Association of Registered Nurses of BC (ARNBC)

ARNBC offered a webinar, “Medical Assistance in Dying: A Year in Review,” with a special focus on the context of nursing. A video and PowerPoint series are available at this URL

  • College of Registered Nurses of BC (CRNBC)

CRNBC offers online course for assessors and prescribers involved in MAiD, running until September 2017. Access this course using this URL

  • Life and Death Matters – In our own corner of education the nurses text, Essentials in Hospice and Palliative Care: A Practical Resource for Every Nurse, includes an extensive section on MAID/Physician Assisted Dying that includes relevant information for nurses in Canada and the US. A preview of the nurses text can be viewed here.

Life and Death Matters also has a newly published resource on MAiD for front line caregivers using the text, Integrating a Palliative Approach: Essentials for Personal Support Workers or Integrating a Palliative Approach: Essentials for Nursing Assistants. This resource discusses the latest legislation about assisted dying (passed after the text was published), the roles of front line caregivers and ways to communicate about assisted dying. The resource is available free of charge – please email us for your copy.

Moving Forward with MAiD

New CNA Code of Ethics for Registered Nurses Includes MAiD

The ethical and moral rights of Canadian registered nurses to make their own decisions about MAiD are protected in the new Code of Ethics for RNs issued by the Canadian Nurses Association.

Part 1: D Honouring Dignity, 12 reads:

Nurses understand the law so as to consider how they will respond to medical assistance in dying and their particular beliefs and values about such assistance. If they believe they would conscientiously object to being involved with persons receiving care who have requested such assistance, they discuss this with their supervisors in advance.

Code of Ethics for Registered Nurses (CNA, 2017)

Participants Needed to Research Nurse’s Perspectives on MAiD

Dr. David Wright and his team are currently recruiting across Canada for a research study on the perspectives of hospice palliative care nurses regarding the ethics of MAiD. They are interviewing registered nurses now and possibly a second time in one year. Anyone interested in participating, but especially anyone from the provinces of Saskatchewan, Manitoba, Quebec, or any of the Maritime provinces, as well as any of the territories, please contact MAiD.Nursing@uottawa.ca.

Input Requested to Expand MAiD to People Not Addressed in Current Legislation

Bill C-14 does not address the needs of people diagnosed with dementia who want to request MAID in advance, nor does it address the requests from mature minors or from individuals who sole medical condition is mental illness. The Council of Canadian Academies (CCA) was asked by the Government of Canada to further study three particularly complex types of requests for MAiD. They have been charged with the following question:

What is the available evidence on, and how does it inform our understanding of medical assistance in dying (MAID) in the case of mature minors, advance requests, and where mental illness is the sole underlying medical condition, given the clinical, legal, cultural, ethical, and historical context in Canada?

Your input is requested and can be provided in one of these ways:

  • Organizations: Submit information here
  • Individuals, you may be able to offer your input through your professional association. For example, the ARNBC is requesting your input as they prepare their submission to the expert panel. Complete their questionnaire before August 18th.

HPNA Position on Assisted Dying

  1. HPNA Position Statements Endorsements – HPNA recently updated 2 new Position Statements listed below. If your association is interested in endorsing the Position Statements, please contact HPNA.

Last Thoughts

My hope is that all individuals will be encouraged and able to participate or not participate in MAID to the degree that they are comfortable, and that every person will be supported with kindness and empathy, just as we desire to provide kindness and empathy to those we care for.

What does this mean in action? I am interested in hearing your views….


[1] http://www.cbc.ca/news/health/medically-assisted-dying-canadians-rob-rollins-1.4056700

[2] https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-dec-2016.html#t1

[3] http://www.dyingforchoice.com/docs/AssistedDyingPracticeInBeneluxWhitepaper1b2016.pdf

[4] http://public.health.oregon.gov/ProviderPartnerResources/EvaluationResearch/
DeathwithDignityAct/Documents/year19.pdf

The Right to Palliative Care

We just attended the Hospice Palliative Care Ontario 2016 Conference in Toronto. Wonderful event with nearly 800 attendees.

Much talk about PAD (Physician Assisted Dying) or MAID (Medical Assistance In Dying). The following day there was an interesting opinion piece in the Globe and Mail by Dr Tom Koch, a gerontologist and ethicist, who provides chronic and palliative consultations. The title of the article, “The next court challenge, the right to better care“.

Koch asks the question, “If the Supreme Court decision enshrines choice as a principle of Canadian justice,  then what choice are we to be offered? If it is between constant pain and an early death, most of us would prefer the latter. Expert palliative care can mitigate physical suffering in, according to experts, perhaps 95% of all cases. But at present, that level of pain control is unavailable to many Canadians. Without its surety, the choice is limited, if not empty, and justice therefore denied because a real full choices is withheld. Similarly, all agree that end stage home care and hospice care can make the last stage of an illness more than bearable. But many Canadians who would choose this, can not, it is not available. And without its insurance, the choices they are offered to care to the end are limited.”

The most important discussion in hospice palliative care today is: How do we integrate palliative care principles, practices and philosophy of care, from time of diagnosis, for people with any life limiting illness, across all care settings?

With the current needs of the dying, and with the anticipation of the increase in number of death annually, it is imperative that we follow the lead of Palliative Care Australia, and recognize that care of the dying person and the family is everybody’s business! And every nurse, every health care worker, every member of the health care team needs to be able to provide, access or refer individuals to services that will address their needs.

In Canada and in the United States, most dying people do NOT receive the services of a specialty hospice and/or palliative care team. The good news is that most dying people do not require the services of a specialty team. However most people who are dying, and their family, can benefit from the integration of palliative principles in the care provided by their general primary care team.

Most dying people can benefit from the principles, practices and philosophy of hospice and palliative care being integrated in care delivered by their primary care providers.

The primary care team may include the nurse and the health care workers on the medical unit, in the emergency department, working in long term care, working in the community, working in the doctor’s office.

This is education that can and should be integrated in core curriculum for all health care workers and nurses (as well as all members of the health care team)!

Nurses and Health Care Workers (AKA PSWs, NAs, HCAs etc) need to know that caring for the dying is part of their work, and they need to develop the competencies to do so.

We have developed our resources for this purpose. And, last month I delivered a webinar, for nurse educators, looking at how they can “Integrate an Educational Approach in Palliative Care“. If you are looking for ideas or inspiration on educating the health care team, then you might want to check out the recording.

On the other hand, if you are a health care worker and want to explore how you can integrate a palliative approach in the setting where you are working, you might be interested in the text and workbook, podcasts and videos.

Canadian Resources  |  American Resources

And finally, if you are a nurse looking for an easy to read, delicious and digestible palliative care resources – the new text, “Essentials of Hospice and Palliative Care: A Practical Resource for Every Nurse” will be available in July 2016!!

Personal reflection: Medical Assistance in Dying

Today Bill C-14 was presented to parliament. big smooth rock in water

Today the Canadian Government introduced legislation to make medical assistance in dying legal. The facts about the proposed legislation can be found here.

People have asked what I think about Medical Assistance in Dying. I have not presented my thoughts openly on this topic, for a number of reasons. Tonight, I will respond to those who have asked, and I will share a few very personal thoughts.

April 14th. My reflection on Medical Assistance in Dying

In an ideal world it would be nice to not have this issue before us. But we do not live in an ideal world.

In an ideal world, people would have access to hospice and palliative care services, holistic person centered care would be available from time of diagnosis through to and following death. But we do not live in an ideal world.

In an ideal world, community would care for one another, people would not be lonely, and needs would be addressed from childhood on, fear would not exist. But we do not live in an ideal world.

In an ideal world, there would be funding to assist community to address sorrows and suffering. But we do not live in an ideal world.

In an ideal world, people would not struggle for air, pain would not saturate a person’s being… but again, we do not live in an ideal world.

Ideal is defined as a standard of perfection or excellence, existing only in the imagination, not real or actual…  And this type of ideal does not exist.

So, for these reasons, I know that there are situations where medical assistance in dying is needed.

I understand that for many people, that this is not about the degree of suffering, but rather the desire to have control over how, when and where people die. I appreciate that as Canadian, North Americans, that autonomy is a most important value. And so, I am satisfied that this is what the Canadian people want.

For me, the lesson that I am forever having to learn, is to let go of control, and to allow life. I think that this may yet be one of my lessons in dying, to let go and let life – and death – occur.

Years ago I heard of a midwife in Australia who commented on the decision that some women were making to choose and plan a cesarean section in advance, preferring the surgery over natural childbirth. The midwife asked, “Have women lost confidence in their ability to birth naturally?” and in reflecting on that comment, I wonder, “Will we… or more importantly, will I have the confidence to die naturally?”

I understand the rationale for this new legislation. I understand the desire to want to choose.

And I will continue to hope that my living and my dying, will afford me the opportunity to go sweetly and naturally into that good night.

Kath

PS, another day I will write about the specifics of this legislation… there are a few things that I am especially glad about.

PPS, You are invited to share your thoughts and feelings here. Please be kind and respectful though. I have no space and time for turning this into a debate… the decision to allow Medical Assistance in Dying has been made. We now look ahead to developing and influencing policy to protect the vulnerable, those who want the service, those who don’t, those who want to assist, and those who do not want to be involved in any way. How are we going to do that? And, as evening and night falls around you, what are your thoughts and feelings? What are your concerns as a person and as a professional? What do you worry about? What are you glad about? What process are you using for understanding and grasping this new legislation?

PPPS, I am honoured to have David Wright from the University of Ottawa provide a piece on Medical Assistance in Dying for the new text for nurses that we are working on. He is a gifted writer, and has done some great research on this topic.