ArticlePDF Available

Investigating Palliative Care Nurse Attitudes Toward Medical Assistance in Dying: An Exploratory Cross‐sectional Study

Authors:

Abstract

Aim:To investigate palliative care nurse attitudes towards medical assistance in dying. Design: An exploratory cross‐sectional study design. Methods: A mailed letter recruited participants with data collection occurring on a secure online survey platform between November 2017 and February 2018. Data analyses included descriptive and bivariate statistics and stepwise linear regression. Results: Palliative care nurse attitudes toward medical assistance in dying were explained by perceived expertise in the social domain of palliative care, personal importance of religion/faith, professional importance of religion/faith and nursing designation. Conclusion: This study reveals the perceived importance of religion, versus religious affiliation alone, as significant in influencing provider attitudes toward assisted dying. Further research is needed to understand differences in attitudes between registered nurses and registered practical nurses and how the social domain of palliative care influences nurse attitude. Impact: Organizations must prioritize nursing input, encourage open interprofessional dialogue and provide support for ethical decision‐making, practice decisions and conscientious objection surrounding medical assistance in dying. Longitudinal nursing studies are needed to understand the impact of legislation on quality and person‐centred end of life care and the emotional well‐being/retention of palliative care nurses.
J Adv Nurs. 2020;76:535–545.  
|
535
© 2019 John Wiley & Sons Ltd

|
  
|
  

ORIGINAL RESEARCH: EMPIRICAL
RESEARCH ‐ QUANTITATIVE
Investigating palliative care nurse attitudes towards medical
assistance in dying: An exploratory cross‐sectional study
Laurie A. Freeman RN, PhD, Associate Professor | Kathryn A. Pfaff RN, PhD, Associate
Professor | Lauren Kopchek BScN, MScN Student | Jordyn Liebman BSc, BScN
Student
         
n/10.1111 /jan .14252
   
 
Correspondence
   
 
  

Abstract
Aim:          

Design: 
Methods:    


Results:           
               
        

Conclusion: 
         
         
   

Impact:        
   
        
            


KEYWORDS
 
care
536 
|
   FREEMAN Et Al.
1 | INTRODUCTION
       
 
           
       

        

    

     
             
           
             
        
             

      



    





             


              


 
     
            
            
              
            
          


1.1 | Background


            
           
 
            

          
      
   
            
  


       
 



        

 
 
 
            
              
         
         
      
      
              

         
        
 
  


        
            
  
 
       
 

      
      
        
         
  
        

     
             
      
  

    
 

    
|
 537
FREEMAN E t Al.
2 | THE STUDY
2.1 | Aims
            
             
   

          

2.2 | Design
 
2.3 | Sample/Participants

    
     
        
             
           
      
         
     
       
             

     
    
   
   
    

 

2.4 | Data collection
2.4.1 | Recruitment
  
               
    ®          
  

2.4.2 | Questionnaires
        
     
      
             
       
          
       
        
         

    

                    
   
           
          
     
        
         
                  
   
    
I have limited experience in this domain     I am able
to consistently and accurately identify and interpret symptoms, rel-
evant problems, and/or issues in this domain  
 
     

2.5 | Ethical considerations
       
        
    
        
  


2.6 | Data analysis
®
               


 
           
           
        
         
  
 

  
     
         
538 
|
   FREEMAN Et Al.
        
        
 
             
            

    
 

2.7 | Validity and reliability
2 . 7.1   | International scales
 

           
             

          


        

       

  
    

       
    
              

        

2 . 7. 2  | The NATMS
     
               
    1 = strongly agree   5 = strongly disagree 
 
     
            
          


3 | RESULTS/FINDINGS
 N

      
       N  
N   N 
            M  
      (M

N
TABLE 1 N
Exploratory Variable N (%) Mean (SD)

 
 
 
 

20–30 
31– 4 0 
41–5 0 
51–6 0 
>60 

Female 
 
 

 
 
 

 
 
 
Divorced 
 
 







 

 
 
 
 
 
 
    
|
 539
FREEMAN E t Al.
       
SD 

3.1 | Factors that may explain palliative care nurse
attitudes towards MAiD
          
        
  
β
p          βp 
β  p    
βpF
p < 
          Fp < 


TABLE 2 
Item
Strongly disagree or
disagree
Neither agree
nor disagree
Agree or
strongly agree
N (%) N (%) N (%)
     
   
    
    
    


  
   
   
    
   
   


  
    
    
   


  
   


  



   
 
 
  
 


  


 
   


 
  
 

  
540 
|
   FREEMAN Et Al.
3.2 | Attitudes towards the provision of MAiD
in hospices
             
            
 N
    

         
N

   
      N
      
             

4 | DISCUSSION


 




              

         
         
       


             
               

   
       



     
          
in Finland.
             



     

        

       
       

  

    
       
     
 
              
           
            
             
         
              
         

Explanatory Variable BSE βt p

     

 
  0.10    


   0.10   

  
   0.14  

Note: R2 = 
TABLE 3  

    
|
 541
FREEMAN E t Al.
4.1 | Explaining palliative care nurse attitudes

      
                
            
      


4.1.1| Perceived expertise in social issues of care
         
    
      

         
        
  
  
           
 
            
       

     

            
          
  
       
         
             


      
        

          
        
       
            
        

            
     


4.1. 2 | Perceived importance of religion
   
          
        

       
   
   
         
              
 
   
              
       
      
             
    


      
     
           
   
        
   
              

4.1.3 | Nursing designation
        
   
   

  
    
    

             
 
           

          
             
           

4.2 | Implications for Practice,
Education, and Research
 
      
             



542 
|
   FREEMAN Et Al.
4.2.1| Nursing practice and education

     
      
     
            
 
               


     
            
            
           


                

  
    
  

          
               
        
         
     

 


 
       
          

     
           

      

            
      
       

       

                
         
           
        
           
 
            


       
       

  
        

        
 
    
  
     

4.2.2 | Future research

        
   
 

     

       


      
             
        
   
             

         
        

             
         

              
           
         
             
              
      

      
     
 

     

    
|
 543
FREEMAN E t Al.
        

        
            
 
  

4.3 | Limitations
               
 
 
   
               
               
       
        
 
     

      
            
             

5 | CONCLUSION
    
             
       
     

        

             
    
       
                

            


ACKNOWLEDGEMENTS


CONFLICT OF INTEREST

AUTHORS CONTRIBUTION
    

  
                  
               
       

               
 
             

ORCID
Laurie A. Freeman 
Kathryn A . Pfaff 
REFERENCES


Neurology87

                 


Journal of Medical Ethics27
             
 Health Law in
Canada36
       
      Journal of Medical Ethics41  

Principles of biomedical ethics.

                
             
        
Journal of Medical Ethics 35  

            

Journal of Medical Ethics 31  
jme.2004.009092
                 
 Nursing Forum, Online Version
1–8     
 
     Supportive Cancer Care
10 
           
Cambridge Quarterly of Healthcare Ethics25

          
             
       Personality
and Individual Differences 105  

544 
|
   FREEMAN Et Al.
     
         
   
                                                          
        JAMA
315 
 

                         
                 
             
               
   Social Science & Medicine63

                 
     

              
 


    Religion and culture   

            

 International Journal of Nursing Studies45  

         
    
      
Journal of Palliative Medicine20 

      
   

 
   Scale development: Theory and application 

                 
 
Journal of Advanced Nursing66

Mail and inter net surveys: t=The tailored design method

              
 Canadian Journal of Nursing
Research37

   Nursing
Ethics 
               
               
    
JAMA316
       
      
      
The New England Journal
of Medicine347
     
in clinical medicine. International Journal of Family Medicine, Article ID
5875 41
                 
Nursing
Ethics16
         
Culture
6
             
 







                              

 Postgraduate Medical Journal 8   






        
       
Journal of Clinical Nursing25
  
       
Canadian Journal of Anesthesia63

               
        
Nursing Philosophy 9      

     Applied logistic regression

           
    
Mortality  
    
MedSurg Nursing 23
 


      
 
       Nursing Ethics23    
   
          
Journal of Hospice and
Palliative Nursing18
00000 000246
          
    
Medicine Health Care and Philosop hy
12
         
Journal of Advanced Nursing57

 

  
Palliative and Supportive Care4
                                        
               
                
Journal
    
|
 545
FREEMAN E t Al.
of Pain and Symptom Management 52  

         
   
         
Science2
         
   
     Palliative Medicine 18
                                                 
         
       
SSRN Electronic Journal       

        
Clinical practice
guidelines for quality palliative care
              
         The
New Zealand Medical Journal 130   


              
 
  
       
  

                  
      
     JAMA 315  
jama. 2015.16210
            
 Journal of Clinical Nursing
   

      Palliative and Supportive
Care3 
  
               
 Palliative Care Nursing, Quality Care to the End of Life  

              
       


        
       
      Nursing Ethics 24
                                             
         
     
    Motivation and Emotion 30


          
             
     BMC Palliative Care 13        
   
Conscientious objection in health care: An ethical analy-
sis             
               
         

SUPPORTING INFORMATION
        
 
How to cite this article: 


 J Adv Nurs. 2020;76:535–545.   
jan.14252
The Journal of Advanced Nursing (JAN)JAN

      JAN        

JAN
Reasons to publish your work in JAN:
High-impact forum:

Most read nursing journal in the world:

Fast and easy online submission: 
Posive publishing experience:
Rapid online publicaon in ve weeks:
Online Open:

... 8 A study from Finland, where assisted dying is illegal, reported that 82% of the 1003 participating nurses agreed that a person has the right to decide their own death; 9 furthermore, 77% personally considered a euthanasia request in certain situations, 9 compared to 48% of 249 participants in a study by Freeman et al with Canadian nurses who provided medical assistance in dying in hospice care settings. 10 In an Australian survey of 1218 participants, 78% of nurses in critical care were more willing to support euthanasia for incurable patients if it was legal, compared to 58% in aged care and 33% in palliative care. 11 In France, 65% of 602 district nurses favored legalizing euthanasia. ...
... 9,12,13 However, in the study by Freeman et al, 75% of 249 palliative care nurses supported an individual's right to decide their own death. 10 Nurses' religiosity has been a strong indicator of negative attitudes toward and disagreement with the legalization of assisted dying; [13][14][15][16] however, a study of nurses in Denmark and Sweden who viewed themselves as religious reported that they had a positive attitude toward euthanasia. 17 Previous studies have also indicated that gender plays an important role, as men were more in favor of euthanasia then women. ...
... 8,9,12 Furthermore, several studies found that younger nurses with less clinical experience were more positive in their attitudes toward assisted dying. 9,10,12,15 Several studies have documented nurses in clinical settings receiving requests for assisted dying from patients, 8,16,[18][19][20][21] but few studies-all conducted in the 1990s-reported the numbers of nurses receiving such requests. 22 Matzo and Emanual reported that 30% of 441 oncological nurses had received at least one request for physician-assisted suicide and 25% for euthanasia. ...
Article
Full-text available
Purpose: The purpose was to investigate: (a) Norwegian nurses' attitudes toward assisted dying, and (b) how much nurses receive requests from terminally ill patients for help in dying. Participants and Methods: A quantitative explorative study was conducted using a web-based cross-sectional survey to collect data. The survey was sent to a total of 734 eligible participants, and 205 clinical nurses participated by completing the survey. Data were analyzed using bivariate statistics and multivariate ordinal regression. Results: The study revealed that 56% of the participating nurses agreed with the statement that physician-assisted suicide should be allowed, and 48% supported legalization of euthanasia. Nurses in pulmonary wards were more positive about the legalization of physician-assisted suicide (OR = 2.98, CI = 1.34-6.66, p = 0.008) and euthanasia (OR = 3.51, CI = 1.58-7.81, p = 0.002) than nurses in oncological wards. Nurses over 30 years old held more negative attitudes about physician-assisted suicide than younger nurses (OR = 0.16, CI = 0.07-0.39, p < 0.001; and OR = 0.45, CI = 0.21-0.96, p = 0.038), and nurses with postgraduate education held more negative attitudes than nurses with a bachelor's degree (OR = 0.46, CI = 0.24-0.88, p = 0.019). A total of 118 nurses (58%) had received at least one request about assisted dying in their clinical practice. Conclusion: Our results provide insight into clinical nurses' attitudes toward assisted dying. Their attitudes were influenced by their age, education, and practice in different wards. Support for legalization of assisted dying is higher in the general Norwegian population than among nurses and receiving requests for assisted dying is not unusual for clinical nurses.
... Supporting MAiD practices requires nurses to develop new understandings of EOL care, moving from traditional palliative approaches that focus on support and symptom management to participating in practices that hasten and directly result in death (Beuthin et al., 2018;Pesut, Thorne, Schiller, et al., 2020). The tension between palliation and MAiD has been particularly difficult for palliative care nurses for whom participation in acts that cause death has been associated with moral and ethical distress (Freeman et al., 2020). Strong religious views have also been associated with nurses' experiences of moral and ethical distress related to MAiD (Elmore et al., 2018;Freeman et al., 2020). ...
... The tension between palliation and MAiD has been particularly difficult for palliative care nurses for whom participation in acts that cause death has been associated with moral and ethical distress (Freeman et al., 2020). Strong religious views have also been associated with nurses' experiences of moral and ethical distress related to MAiD (Elmore et al., 2018;Freeman et al., 2020). This is consistent with findings from European countries with longer histories of euthanasia, where nurses with strong religious views have been found to be less supportive of MAiD-related EOL practices (Francke et al., 2016;Inghelbrecht et al., 2009). ...
... The small but growing scholarship related to MAiD highlights the need for ongoing education regarding nursing roles and responsibilities in relation to the regulatory environment (Beuthin et al., 2018;. There is also a call for more education to support moral and ethical decision-making (Freeman et al., 2020;Schiller et al., 2019). In a recent review of regulatory documents, Pesut and colleagues (2019) called attention to and specified the range of responsibilities related to MAiD that might fall to regulated nurses, such as knowledge of current standards, policies, and legislation; strong therapeutic skills to support communication and assess spiritual and cultural needs; self-reflection related to moral and ethical implications; and support for collaboration and coordination of care. ...
Article
Full-text available
Background: Recent legislation regarding medical assistance in dying (MAiD) has important implications for nursing practice and education. It follows that Canadian nursing programmes must integrate theoretical and clinical practice related to MAiD in current curricula. Understanding student knowledge and comfort regarding MAiD provides important direction for developing curricula. Purpose: To explore the understanding and comfort levels of BSN students regarding MAiD. Methods: An applied health research methodology drawing on Interpretive Description was employed. Forty BSN students were surveyed before receiving MAiD education delivered through coursework and clinical experiences; 32 students participated in post intervention surveys; six students participated in individual interviews. Results: Three major themes emerged from data analysis: Prior Experience and Lack of Experience; Personal Beliefs and Role Challenges; Need for Knowledge. Student understandings and comfort level levels related to MAiD were strongly influenced by their previous experiences, personal values and beliefs, and knowledge of MAiD policies and practices. Both theory courses and clinical experiences related to MAiD had positive impacts on students’ knowledge and comfort levels. Conclusions: Study findings draw attention to the need for improved education related to end of life and MAiD through both theory courses and clinical practicum experiences to improve student knowledge and comfort levels.
... Four major themes and factors that influence knowledge, attitudes, and beliefs about MAiD were evident from the literature: (i) endogenous or individual factors such as age, gender, personally held values, religion, religiosity, and/or spirituality [35][36][37][38][39][40][41][42], (ii) experience with death and dying in personal and/or professional life [35,40,41,[43][44][45], (iii) training including curricular instruction about clinical role, scope of practice, or the law [23,36,39], and (iv) exogenous or social factors such as the influence of key leaders, colleagues, friends and/or family, Prefer not to say 0 0 professional and licensure organizations, support within professional settings, and/or engagement in MAiD in an interdisciplinary team context [9,35,46]. Studies of nursing students also suggest overlap across these categories. ...
... Knowledge questions were refined to reflect current MAiD legislation, policies, and regulatory frameworks. Falconer [39] and Freeman [45] studies were foundational sources for item selection. Additionally, four case studies were written to reflect the most recent anticipated changes to MAiD legislation and all used the same open-ended core questions to address respondents' perspectives about the patient's right to make the decision, comfort in assisting a physician or NP to administer MAiD in that scenario, and hypothesized comfort about serving as a primary provider if qualified as an NP in future. ...
Article
Full-text available
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.
... Assistert død er et kjent internasjonalt begrep (Elmore et al., 2018;Richardson, 2022;Wilson, 2019). Utfordringen med temaet er at det benyttes ulike begreper om samme handling i ulike land (Freeman et al., 2020;Penman et al., 2022). I Norge ser det ut til å vaere uavklart hvilket begrep som skal benyttes: aktiv dødshjelp, dødshjelp eller assistert død (Magelssen, 2020;Materstvedt & Kaasa, 2016;Materstvedt, 2022;Moen & Sterri, 2019). ...
... Ettersom assistert død er blitt legalisert i flere land og stater, har forskningslitteraturen gitt innblikk i helsepersonells erfaringer med dette (Bellens et al., 2019;Beuthin et al., 2018;Brooks, 2019;De Bal et al., 2006;Freeman et al., 2020;Wilson et al., 2019). I 2016 ble assistert død legalisert i Canada og i 2021 i New Zealand, hvor spesialutdannede sykepleiere, «nurse practitioners», fikk myndighet til å utføre assistert død på lik linje med leger. ...
Article
Full-text available
Nursesʼ Competence and Role in the Face of Assisted Death Requests – A Qualitative Study. Background: Assisted death is not legal in Norway. Nurses receive requests from terminally ill patients and perceive this as difficult. Research shows that nurses have limited professional knowledge of this topic. Methods: The study has a qualitative design with a phenomenological hermeneutic approach. Individual interviews of clinical nurses were analyzed with thematic analysis. Results: The nurses had limited theoretically and clinically based knowledge of the topic from basic education; instead, they received knowledge from the media. Nurses with further education in palliative pain relief had received information on this topic. The nurses perceived their own role as unclear in handling requests for assisted death, and the conversations about death were often left to other professions. Conclusion: Inadequate knowledge of assisted dying among qualified nurses presupposes a safe and professional framework, guidance, and support for professional development from the experienced nurses and the interdisciplinary team. Professional knowledge development about assisted death needs to be elucidated in the clinic, in education, and in research contexts.
... Die Studienergebnisse untermauern, dass die Konfrontation mit und die Reaktion auf Todes-und Suizidwünsche zu einer situativen moralischen Überforderung und zu moralischer Ungewissheit auf Seiten der professionell Pflegenden führen. Dies insbesondere dann, wenn sie situativ unsicher dahingehend sind, welche Hand-lungsweise aus ethischer Perspektive geboten ist (Hol et al. 2023;Richardson 2023;Kremeike et al. 2021aKremeike et al. , b, 2020Freeman et al. 2020;Castelli Dransart et al. 2017;Elmore et al. 2016;De Bal et al. 2006). Morley et al. (2023) benennen die moralische Ungewissheit (im Original "moral uncertainty") als mögliche Ursache von Moral Distress. ...
Article
Full-text available
Zusammenfassung Todes- und Suizidwünsche älterer Menschen stellen ein relevantes und moralisch herausforderndes Thema für Pflegefachpersonen dar. Insbesondere im Zusammenhang möglicher Wünsche nach Suizidassistenz wächst das Potenzial moralischer Ungewissheit bis hin zu Moral Distress. Im Setting der ambulanten und stationären Langzeitpflege erweist sich die professionelle Sensibilität und ethische Einordnung gegenüber geäußerten Todes- und Suizidwünschen als besonders bedeutsam, denn sowohl die Suizidraten als auch die Anfragen nach Suizidassistenz sind Studien zufolge bei Menschen über 65 Jahren hoch. Dieser Sachverhalt unterstreicht zugleich die Bedeutsamkeit der jüngst auch durch die Bundesregierung gestärkten Suizidprävention und den Auftrag, ein entsprechendes Gesetz hierfür auf den Weg zu bringen. Die situative Konfrontation der Pflegefachpersonen mit Todes- und Suizidwünschen kann aufgrund der aktuell in der Praxis vorherrschenden rechtlichen Unsicherheiten – so unsere Hypothese – ein ethisches Spannungsfeld zwischen einem vorurteilsfreien, offenen, empathischen und respektvollen Aufgreifen von Todes- und Suizidwünschen einerseits und dem Ziel der Suizidprävention andererseits hervorrufen. Internationale Studien verweisen auf das Potenzial von Moral Distress von Pflegefachpersonen in der Konfrontation mit Todes- und Suizidwünschen. Diese Erkenntnisse und die Bezugnahme auf die aktuellen rechtlichen Unsicherheiten und Rahmenbedingungen im nationalen Kontext untermauern die Bedeutsamkeit der professionsbezogenen Auseinandersetzung mit der Thematik, die Notwendigkeit (zukünftige) Pflegefachpersonen für potenzielle ethische Spannungsfelder zu sensibilisieren und einen kompetenten Umgang mit der einhergehenden moralischen Ungewissheit zu ermöglichen.
... It is believed that this condition is caused by the fact that assisted dying is an action that unnaturally accelerates death and contradicts the principles of the palliative care philosophy (Terkamo-Moisio et al. 2017). However, Freeman et al. (2020) reported that 75% of 249 palliative care nurses supported individuals' right to decide on their death. In a study conducted in Germany by Zenz et al. (2015), 4% of nurses working in palliative care services stated that they would like to apply for active euthanasia if requested by patients with a terminal illness. ...
Article
Full-text available
This review was planned to present an overview of the findings in the scientific literature on euthanasia, palliative care, and nurses' attitudes and behaviors. A literature search was done in "EBSCO," "PubMed" databases, and "Google Scholar" search engines. In the study, a search was made between January and March 2023 using the keywords "palliative care," "euthanasia," and "nurse attitudes." Articles published in English and accessible were included in the research. Palliative care practices differ according to the health system, socioeconomic status, cultural conditions, geographical location, and education levels of countries On the other hand, discussions on the integration of euthanasia into palliative care practices continue. While palliative care practices differentiate in countries where euthanasia has been legalized, scientific, legal, religious, and ethical discussions continue in countries where euthanasia is not legal. There are many different variables, such as age, gender, professional experience, and cultural and religious factors, that affect nurses' attitudes and behaviors on this issue. It can be suggested that the results of the research, which will evaluate the factors affecting the attitudes of nurses toward euthanasia, death and terminally ill patients, include social changes in order to provide a literature and database in this field.
... This is because these are often reflected in complex and nebulous dialogues relating to professional, interpersonal, social, emotional, and moral concerns. 22,23 Nevertheless, a relatively strong viewpoint emerged from the data that generally supported beneficence/nonmaleficence arguments. These arguments generally outweighed other considerations such as patient autonomy and their right to choose. ...
Article
Full-text available
This qualitative study explores the viewpoints of hospice nurses about end-of-life issues and proposed legislation that would allow assisted dying/euthanasia to be performed in New Zealand. The study uses data that were obtained from in-depth interviews with 15 experienced Palliative Care Nurses who were all working at various hospices around New Zealand. A thematic analysis process was used to develop a thematic framework, and the results indicated that there were at least 3 main themes supported by a number of related sub-themes. These main themes were as follows: (a) personal values converge with professional ones when hospice nurses are asked to offer their viewpoints, (b) common end-of-life practices are not regarded by hospice nurses as acts of euthanasia, and (c) hospice nurses are greatly concerned about the effects of a euthanasia law on their profession and its relationships with the public. Our findings reveal that the hospice nurses in New Zealand largely hold negative viewpoints about the introduction of legalized assisted dying practices, arguing that such changes will present major challenges to their perceived role within their profession and within society. These findings suggest that this research should have a considerable primary impact among hospice and palliative care nurses in other nations.
... This is because these are often reflected in complex and nebulous dialogues relating to professional, interpersonal, social, emotional, and moral concerns. 22,23 Nevertheless, a relatively strong viewpoint emerged from the data that generally supported beneficence/nonmaleficence arguments. These arguments generally outweighed other considerations such as patient autonomy and their right to choose. ...
Article
Full-text available
This qualitative study explores the viewpoints of hospice nurses about end-of-life issues and proposed legislation that would allow assisted dying/euthanasia to be performed in New Zealand. The study uses data that were obtained from in-depth interviews with 15 experienced Palliative Care Nurses who were all working at various hospices around New Zealand. A thematic analysis process was used to develop a thematic framework, and the results indicated that there were at least 3 main themes supported by a number of related subthemes. These main themes were as follows: (a) personal values converge with professional ones when hospice nurses are asked to offer their viewpoints, (b) common end-of-life practices are not regarded by hospice nurses as acts of euthanasia, and (c) hospice nurses are greatly concerned about the effects of a euthanasia law on their profession and its relationships with the public. Our findings reveal that the hospice nurses in New Zealand largely hold negative viewpoints about the introduction of legalized assisted dying practices, arguing that such changes will present major challenges to their perceived role within their profession and within society. These findings suggest that this research should have a considerable primary impact among hospice and palliative care nurses in other nations.
Article
Objectives: Medical Assistance in Dying (MAiD) has been legal in Canada since June 2016. A person can receive MAiD if their suffering cannot be relieved under conditions that they consider acceptable. Informed consent requires that the person requesting MAiD has received all the information needed to make their decision; that is, medical diagnosis and prognosis, available treatments including palliative care. The evaluation of unbearable suffering is known to be challenging as suffering is often psychological, existential, and social in nature. While interventions to relieve suffering exist, it is unclear how suffering is assessed and addressed in the literature on MAiD practice. No scoping review exists on the topic in Canada. The aim of this study was to understand how the concept of suffering was approached within the Canadian MAiD grey (GL) and scientific (peer-reviewed) literature (SL), specifically: 1- How suffering is defined and assessed in the context of MAiD in Canada and 2- Which interventions in response to suffering are recommended within the process of obtaining informed consent for MAiD and throughout the process of MAiD itself. Methods: A scoping review was conducted based on PRISMA-SR guidelines. SL articles (N = 1027) were identified from a review of 6 databases and GL documents (N = 537) were obtained from the provinces of Quebec, Ontario and British Columbia. Documents were analyzed using NVivo with coding by two-raters and continuous team discussions. Results: A multidimensional definition of suffering, akin to the concept of total pain, is used. The assessment of suffering is based upon patients' reports. Tools to aid in the assessment are not comprehensively covered. Specific interventions to address suffering were often focused on active listening and the management of physical symptoms. No specific interventions were mentioned and there was no reference to clinical practice guidelines in the grey literature to address other components of suffering. The use of a multidisciplinary approach is suggested without specifying the nature of involvement. Conclusions: Our review indicates that published guidelines of MAID assessments could include clearer structure around the assessment and management of suffering, with suggestions of tools that may help clarify types of suffering and reference to clinical practice guidelines and interventions to holistically attend to patient suffering with an attention on non-physical symptoms. Guidelines would benefit from clearer explanations of how members of an interdisciplinary teams could be coherently coordinated.
Article
Full-text available
It is well known that there are disagreements between the proponents of palliative care and of euthanasia or assisted dying, often with little common ground,shaping the end of life discourse internationally. Advocacy documents or ‘declarations’constitute a significant feature of this discourse. The aim of this study was to explore the content of such declarations and to focus on what they can tell us about palliative care and assisted dying and their dispositions towards one another. 104 declarations were identified and included in the study, covering the period 1974 to 2017. These declarations were analysed following the principles of thematic content analysis. We classified them based on their primary purpose: those with the goal of advocating for palliative care services, education and research were grouped under ‘palliative care declarations’; those with the primary objective of advocating for or against euthanasia/assisted dying were classified as “euthanasia/assisted dying declarations”. Our analysis revealed that the content of the declarations could be broadly categorised into three dimensions: framing, claiming and demanding. We demonstrate that these declarations reveal a struggle over the construction of meanings relating to palliative care and assisted dying and constitute a valuable resource for the analysis of an unfolding debate.
Article
Full-text available
Medical assistance in dying (MAiD) represents a historic change in Canadian society and the provision of end‐of‐life care. In this descriptive narrative inquiry, 17 nurses were interviewed during the first 6 months of assisted dying becoming a legal option for patients in Canada. Nurses’ experiences of either providing care for a patient who had chosen MAiD, or declining to participate in MAiD, were explored. Findings describe three themes and eight storylines of the impact of MAiD on nurses’ view of the profession, clinical practice, and personally. While most nurses perceived MAiD as an extension of the profession and their nursing practice, a small number also expressed moral distress as they grappled with assisted dying. Narratives illustrated an ongoing sensemaking process and spectrum of emotions. These findings offer insight and provide direction for nurses and managers in this new clinical and legal reality. Further research is needed to understand more fully the moral distress of some nurses, as well as the importance of communicating openly and nonjudgmentally with patients, families, and the health‐care team.
Article
Full-text available
Background: Reports about regulations and laws on Euthanasia and Physician Assisted Suicide (PAS) are becoming increasingly common in the media. Many groups have expressed opposition to euthanasia and PAS while those in favor argue that severely chronically ill and debilitated patients have a right to control the timing and manner of their death. Others argue that both PAS and euthanasia are ethically legitimate in rare and exceptional cases. Given that these discussions as well as the new and proposed laws and regulations may have a powerful impact on patients, caregivers, and health care providers, the International Association for Hospice and Palliative Care (IAHPC) has prepared this statement. Purpose: To describe the position of the IAHPC regarding Euthanasia and PAS. Method: The IAHPC formed a working group (WG) of seven board members and two staff officers who volunteered to participate in this process. An online search was performed using the terms “position statement”, “euthanasia” “assisted suicide” “PAS” to identify existing position statements from health professional organizations. Only statements from national or pan-national associations were included. Statements from seven general medical and nursing associations and statements from seven palliative care organizations were identified. A working document including a summary of the different position statements was prepared and based on these, an initial draft was prepared. Online discussions among the members of the WG took place for a period of three months. The differences were reconciled by email discussions. The resulting draft was shared with the full board. Additional comments and suggestions were incorporated. This document represents the final version approved by the IAHPC Board of Directors. Result: IAHPC believes that no country or state should consider the legalization of euthanasia or PAS until it ensures universal access to palliative care services and to appropriate medications, including opioids for pain and dyspnea. Conclusion: In countries and states where euthanasia and/or PAS are legal, IAHPC agrees that palliative care units should not be responsible for overseeing or administering these practices. The law or policies should include provisions so that any health professional who objects must be allowed to deny participating.
Chapter
This chapter discusses ethical and legal aspects of euthanasia and assisted dying. It first examines the non-voluntary termination of life, covering the relationship between medical treatment and assistance in dying as a matter of failure to treat, and the philosophical concept of ‘double effect’. The chapter then discusses activity and passivity in assisted dying; dying as an expression of patient autonomy; suicide and assisted suicide; physician-assisted suicide; and assisted dying in practice.
Article
Aims The purpose of this integrative review was to identify themes and gaps in the literature to stimulate researchers to develop strategies to guide decision‐making among clinical nurses faced with ethical dilemmas. Background The concept of ethical dilemmas has been well explored in nursing because of the frequency of ethical dilemmas in practice and the toll these dilemmas can take on nurses. Although ethical dilemmas are prevalent in nursing practice, frequently leading to moral distress, there is little guidance in the literature to help nurses resolve them. Design This paper is an integrative review of published research from 2000 to 2017. Methods The keywords ethics, ethical dilemmas and nurs* were searched in CINAHL, PubMed, OVID, and SCOPUS. Exclusion criteria were sources not available in English, not in acute care, and without an available abstract. Seventy‐two studies were screened; 35 were retained. Garrard's matrix was utilized to analyze and synthesize the studies. Results Ethical dilemmas arose from end‐of‐life issues, conflict with physicians or families, patient privacy concerns, and organizational constraints. Differences were found in study location, and yet international research confirms that ethical dilemmas are universally prevalent and must be addressed globally to protect patients and nurses. Conclusions This review offers an analysis of the available evidence regarding ethical dilemmas in acute care, identifying themes, limitations, and gaps in the literature. The gaps in quantitative intervention work, U.S. paucity of research, and lack of comparisons across practice settings/nursing roles must be addressed. Further exploration is warranted in the relationship between ethical dilemmas and moral distress, the significance patient physical appearance plays on nurse determination of futility, and strategies for pain management and honesty. This article is protected by copyright. All rights reserved.
Article
Background: Assisted dying (AD) has been legalised by statute or court decisions in at least 15 jurisdictions internationally. Nonetheless, only three medical professional bodies (and none in nursing) across those jurisdictions have proactively developed authorised policy, practice standards, guidelines or protocols, or other professional supports for health practitioners who may legally participate in AD services, and the majority internationally remain formally opposed to AD. There is a perceived likelihood that AD may be legalised in New Zealand soon. Aim: This study explored the views of doctors and nurses as to support for or opposition to legalising AD, including reasons for those views, what might deter generally willing doctors and nurses from providing AD services and what professional supports were perceived as essential or desirable to enable willing engagement in AD service provision. Results: While only 37% of doctors supported legalising AD in New Zealand, 67% of nurses were supportive. Of those respondents who were willing in principle to provide AD services, large majorities identified a range of practical and ethical professional supports as essential to safe practitioner engagement. Those respondents overwhelmingly saw the provision of most of those supports as the responsibility of the medical and nursing professional bodies. Conclusion: There is a substantial cohort of doctors and nurses in New Zealand who support legalising AD, potentially sufficient for reasonable seeker access to AD services once legalised. However, many doctors in particular still oppose AD, and international research shows that the main barrier to access to legal AD is a lack of capacity and capability among health professionals, due in large part to several related factors, in particular: a lack of either accredited training and education for the AD provider tasks and roles; inadequate immunities within the legislation to protect participating professionals; and most importantly, a lack of practice standards and guidelines authorised by the relevant medical and nursing professional bodies. The challenge is for such protections to be available well in advance of legalisation, so that health practitioners are not at risk ethically or otherwise in early participation.
Article
The issue of physician-assisted suicide is a highly contentious social issue and thus there is importance in understanding the factors that predict attitudes in this domain. In the current study we sought to examine individual differences in moral sentiment towards physician-assisted suicide with a particular focus on religion/religiosity, political ideology, authoritarianism, and Big Five personality traits, all of which were identified in an extensive review of previous studies as potentially relevant predictors. Based on N = 1598 respondents from the Baylor Religion Survey (US) our results indicated an independent role for each of the predictors: being a Protestant or a Catholic (vs. no religion), higher levels of religiosity, higher levels of conservativism (vs. liberalism), and higher levels of authoritarianism uniquely predicted lower levels of support for physician-assisted suicide. Moreover, higher levels of extraversion independently predicted greater support for physician-assisted suicide. These results confirm a set of previously described predictors in an independent data set and extend prior research by showing that they independently predict moral sentiment towards physician-assisted suicide when modelled jointly. In summary, moral sentiment towards physician-assisted suicide reflects individual differences in a broad range of social and psychological factors.
Article
In the most significant constitutional decision of the last generation, Carter v. Canada, the Supreme Court of Canada reversed itself and decided that it was possible for Parliament to enact safeguards that would be adequate to protect persons who are vulnerable in times of weakness, then proceeded to declare that Canadians were entitled to a s. 7 Charter right to physician-assisted death. David Baker and Gilbert Sharpe accepted the challenge issued by the Court and drafted a Bill to amend the Criminal Code in a manner they believed would strike a constitutional balance between providing access to the right declared by the Court and protecting the vulnerable. This article represents their attempt, along with co-author Rebeka Lauks, to explain many of the key provisions in their draft. Amongst the most noteworthy are their attempts to ensure that those choosing PAD are informed about quality of life, as well as treatment choices; to define vulnerability and to install safeguards adequate to protect persons while vulnerable; and finally a prior review process that would ensure both ready access to the Charter right declared by the Court and consistent and transparent application of the law. The authors have attempted to establish an alternative model to that currently in effect in the Benelux countries, which they regard as having been ineffective in achieving any of these objectives.
Article
Importance: The increasing legalization of euthanasia and physician-assisted suicide worldwide makes it important to understand related attitudes and practices. Objective: To review the legal status of euthanasia and physician-assisted suicide and the available data on attitudes and practices. Evidence review: Polling data and published surveys of the public and physicians, official state and country databases, interview studies with physicians, and death certificate studies (the Netherlands and Belgium) were reviewed for the period 1947 to 2016. Findings: Currently, euthanasia or physician-assisted suicide can be legally practiced in the Netherlands, Belgium, Luxembourg, Colombia, and Canada (Quebec since 2014, nationally as of June 2016). Physician-assisted suicide, excluding euthanasia, is legal in 5 US states (Oregon, Washington, Montana, Vermont, and California) and Switzerland. Public support for euthanasia and physician-assisted suicide in the United States has plateaued since the 1990s (range, 47%-69%). In Western Europe, an increasing and strong public support for euthanasia and physician-assisted suicide has been reported; in Central and Eastern Europe, support is decreasing. In the United States, less than 20% of physicians report having received requests for euthanasia or physician-assisted suicide, and 5% or less have complied. In Oregon and Washington state, less than 1% of licensed physicians write prescriptions for physician-assisted suicide per year. In the Netherlands and Belgium, about half or more of physicians reported ever having received a request; 60% of Dutch physicians have ever granted such requests. Between 0.3% to 4.6% of all deaths are reported as euthanasia or physician-assisted suicide in jurisdictions where they are legal. The frequency of these deaths increased after legalization. More than 70% of cases involved patients with cancer. Typical patients are older, white, and well-educated. Pain is mostly not reported as the primary motivation. A large portion of patients receiving physician-assisted suicide in Oregon and Washington reported being enrolled in hospice or palliative care, as did patients in Belgium. In no jurisdiction was there evidence that vulnerable patients have been receiving euthanasia or physician-assisted suicide at rates higher than those in the general population. Conclusions and relevance: Euthanasia and physician-assisted suicide are increasingly being legalized, remain relatively rare, and primarily involve patients with cancer. Existing data do not indicate widespread abuse of these practices.
Article
The Criminal Code of Canada prohibits persons from aiding or abetting suicide and consenting to have death inflicted on them. Together, these provisions have prohibited physicians from assisting patients to die. On February 6, 2015, the Supreme Court of Canada declared void these provisions insofar as they "prohibit physician-assisted death for a competent adult person who (1) clearly consents to the termination of life and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition." This declaration of invalidity was scheduled to take effect one year (later extended by six months) after the ruling, to give the government time to put legislation in place. We trace the history of this decision, discuss how it has forever changed the debate on physician-assisted dying, and identify the issues that must be resolved to write the legislation. Of special importance here are the topics of access, safeguards, and conscientious objection.