Medical Assistance in Dying
UBC Nursing DIALOGUES
Since June 2016, it has been legal in Canada for an eligible person suffering intolerably from a grievous and irremediable medical condition to request assistance from a doctor or nurse practitioner in voluntarily ending their life. Nevertheless, ensuring that the Medical Assistance in Dying (MAiD) care option is accessible and equitable to British Columbians is an ongoing process.
In March 2019, the UBC School of Nursing’s Dr Sally Thorne moderated a dialogue with a clinical nurse specialist (Laurel Plewes), nurse practitioner (Pamela Trant), nurse ethicist (Dr Paddy Rodney), and researcher (Dr Barb Pesut) to explore the nuances of this health care landscape almost three years after the initial legislative changes.
As a pediatric palliative care nurse on the brink of completing her MSN at UBC on the topic of assisted dying legislation, Laurel Plewes was the first nurse recruited to the Assisted Dying Program when Vancouver Coastal Health launched it in January 2017.
In that role, Plewes is front row to the full spectrum of contexts in which MAiD is provided. In the most well-managed cases, a nursing leader supports nursing staff through the process of understanding and enacting care options. When this support happens, patients are guided through the process unconstrained by administrative burdens or situational tensions, nursing staff report feeling comfortable to engage with the process and debrief with colleagues and leaders, and families can focus on saying farewell and grieving. When the process goes poorly, this can often be attributed to nursing leaders failing to engage or failing to invite another leader to respond. These leadership gaps can result in staff becoming conflicted or even divided while patients and families are left to advocate for themselves.
“Nursing has a massive part to play in the patient outcome, the family outcome, and the staff feelings about this care option,” explained Plewes. She therefore urges all nurses— regardless of their specialties—to equip themselves to respond compassionately and knowledgeably when queries about MAiD arise.
In Canada, nurses and Nurse Practitioners (NPs) play a key role in MAiD, and nursing has been “at the table” in the ongoing policy dialogue from the beginning. NPs can do the assessment, prescribing, and the provision of assisted dying. It is one of the few areas where NPs do not have physician oversight other than specialist consults as needed.
NP Pamela Trant is the first to applaud that the legislation makes it possible to help someone truly suffering towards the end of their life. “It’s absolutely remarkable that we have this option in Canada now. Modern medicine has tinkered with people’s health so much to give longevity of life, but we haven’t offered quality of life in all cases,” she adds.
Canadian legislation sets out the eligibility requirements for MAiD, the procedural safeguards for protecting patients, and the process by which MAiD can be provided. Important as they are, these can also create substantial administrative processes and logistical hurdles, and some patients are still not eligible. In particular, requests from mature minors, advance requests from patients not yet incapacitated, and requests where existential suffering from mental illness is the sole underlying concern remain ineligible.
The federal government tasked the Council of Canadian Academies (CCA) with interpreting the available evidence to inform future decisions regarding these three patient groups. Dr Paddy Rodney, an associate professor in the UBC School of Nursing, was recruited to contribute to this complex evidence assessment process. The reports are now available on the CCA website.
Reflecting on that experience, Dr Rodney highlighted the ongoing challenges of expanding the availability of MAiD to Canadians while access to comprehensive palliative and chronic care services is still inadequate. She also advocated for ongoing work to prepare supports for patients, their families, and care providers to make ethical decisions about MAiD, including supports for those who conscientiously object to MAiD.
Dr Barb Pesut, a UBCO Nursing Professor and Canada Research Chair, shared preliminary results from the ongoing program of research she leads on nurses’ engagement with MAiD. In addition to the many requirements associated with MAiD assessment and coordination of provision, nurses are having to establish an intimate rapport with clients more quickly, learn to say goodbye to patients more explicitly, and monitor for capacity while providing high quality pain and symptom management.
Dr Pesut shared that the emotional response a nurse may have to a MAiD experience can be “unpredictable and ineffable.” Some nurses in a study she is co-leading with Dr Thorne have considered the moral labour associated with MAID to be so difficult that they may need to leave their profession or change positions, while others have found supporting patients through MAiD to be among the most important nursing work of their careers.
The role of “orchestrating death” can be a fraught one for even the most experienced nurses—from ensuring patient autonomy throughout a complex leave-taking journey, to upsetting the normal order of not knowing when death will occur, to witnessing the startling greying of patients’ complexions that happens when medication is delivered.
For many nurses, this work is only possible through strong teams and their own supportive families. It is deeply dependent on nurses’ willingness to revisit their reasons for working at the threshold of life and death. Dr Pesut describes nurses’ engagement with MAiD as reconciling the malleable influences of intuition, reasoning, and experience.
As the legislative framework changes to enable more Canadians to access a wider range of care options as they near the end of life, nursing will continue to be at the forefront of promoting safe, compassionate, competent, and ethical care.
To listen to the recorded session: nursing.ubc.ca/MAIDdialogues