Physician-assisted dying (MAID) was legalized in Canada in 2016. Since then, there has been a year-over-year increase in the number of Canadians having access to a MAID death. The most recent data from 2019 to 2020 shows a 34.2% increase in the number of Canadians accessing MAID.

Bill C-7, passed in June 2021, changed the eligibility criteria by removing the “natural death has become reasonably foreseeable” requirement. Therefore, more Canadians may be eligible for MAID.

During the pandemic, 23% of healthcare providers participating in an international survey said inquiries or requests for assisted dying had increased “somewhat” or “significantly”. The pressures of MAID and COVID-19 have caused at least one Canadian province to temporarily suspend referrals for patients seeking access to MAID.

Non-participation in MAID:

Health care providers who are willing to participate in patient assessment and the provision of MAID are essential to supporting Canadians who wish to access MAID. It is therefore important to understand the factors that influence practitioners’ decision not to participate in MAID.

David Lametti, Minister of Justice and Attorney General of Canada, delivers a statement on Bill C-7 on Parliament Hill in Ottawa in March 2021. The bill removed the criterion of reasonably foreseeable death from eligibility for MAID.
THE CANADIAN PRESS/Sean Kilpatrick

As an end-of-life researcher and registered nurse, I investigated this question with the support of my thesis committee. This research has highlighted the complex and intertwined reasons why healthcare professionals may not participate in MAID.

These factors can be divided into internal and external factors, but it is also important to recognize that there are consciousness-based and non-consciousness-based factors that influence non-participation.

Internal factors

Several personal or internal factors influenced the non-participation. These included general discomfort caring for dying patients as well as the provider’s prior personal and professional experiences related to death and dying. Additionally, MAID did not fit with some practitioners’ approaches to end-of-life care.

Other factors that influenced non-participation included practitioners’ opinions of their professional duty. MAID did not align with the faith or spiritual beliefs of some practitioners, and some said they could not imagine being at peace with the decision to participate in physician-assisted dying.

Health practitioners also considered how they were likely to react emotionally to their participation in MAID. They were concerned about the future impact of their participation in MAID in terms of potential risk of post-traumatic stress disorder and burnout.

External factors

  • Health system factors: The health system influenced non-participation. This included working for an organization with an institutional conscientious objection to MAID and the uncertainty of working in a rapidly changing legal landscape in terms of MAID regulation. There were also concerns about adequate access to alternatives to MAID, such as palliative care and chronic care home support. Some nurse practitioners said they did not participate in MAID due to limited job or practice descriptions at their current employer or a lack of billing codes that would allow them to be paid for these services. .

  • Community factors: Reasons for non-participation also included assessment of ‘community consciousness’, perception of a lack of openness in end-of-life discussions, and prevailing religious beliefs in the community. Healthcare practitioners worried about the impact of having to reduce or cancel other services in an already busy practice to save time to provide MAID care to a single patient. They also did not know if or how culture influenced the patient’s perception of MAID, or the patient’s perception of them as health care professionals if they participated, or if participation would alter patient confidence. the community in them.

Cropped image of person in white coat standing behind seated elderly person holding hands
The healthcare practitioner-patient relationship influenced non-participation. A long relationship with the patient could make participation in MAID uncomfortable and difficult.
(Shutterstock)
  • Practice factors:
    For some health professionals, their decision not to participate in MAID was influenced by a lack of policy and program knowledge or skills to participate in the assessment or delivery of MAID. Another reason was adequate compensation for the time and overhead involved. Others said they did not understand the optimal care model for MAID (for example, whether MAID is provided by family physicians, end-of-life care practitioners, or MAID teams ). Others indicated that MAID exceeded their clinical interest and their strengths in practice.

  • Visibility factors:
    How participation in MAID would be perceived by colleagues, clinic staff, and patients also influenced the non-participation of health care providers. This included fear of disapproval from colleagues, fear that participation would harm relationships with patients and their relationship with their faith community, and fear that participation would be interpreted as patient abandonment.

  • Risk factors:
    Health care providers considered the risk to themselves, their practice and their families. Specifically, the risk associated with professional discipline if the patient or family disagrees with their assessments, the risk that colleagues will complicate their professional lives, and the perceived risk of personal physical harm or violence towards them- themselves or their families.

  • Temporal factors:
    Concerns about competing clinical demands, time-limited appointments that do not accommodate end-of-life conversations, and lack of time to provide quality MAID care also influenced non-participation. Some health care providers were unwilling to undertake new practices at their current stage of their careers (eg, near retirement) and others noted a lack of time for ongoing training in MAID.

  • Family factors of the patient:
    Other factors that influenced non-participation in MAID were related to the patient’s family. Health care providers expressed concern that participation would impact the care of other family members and that there was a lack of support for the family before, during and after MAID . They also examined the potential challenges of interfamily conflict around the patient’s choice of MAID and the impact of MAID death on future family dynamics.

  • Patient relationship factors:
    Another factor was the relationship between the healthcare professional and the patient. A long relationship with the patient could make participation in MAID uncomfortable and difficult. Others noted that a long history with a patient would promote open discussions about the reasons for their non-participation in MAID.

Support for health practitioners

My research describes a model of non-participation in formal MAID processes. In terms of conscientious and non-conscience factors, it is essential to differentiate between a conscientious objection at MAID and non-participation in AMM because health practitioners need different support for these.

Steps that could help health practitioners considering participating in MAID include clarifying regional models of care, which vary between provinces and territories.

Practice-oriented MAID education could include not only policy and legal aspects, but also pragmatic issues such as obtaining medications and administrative requirements, as well as discussions of relevant factors such as skills in communication and religious knowledge.

Recognizing practice issues, the investment of time and relationships required to provide MAID, and developing fair compensation policies for health professionals who provide it, can support greater uptake of MAID.

Support for health practitioners will be essential to a sustainable and healthy health care system for Canadians.