Introduction
Methods
Setting and participants
Data collection
Data analysis
Results
Patient characteristics (n = 24) | |
Gender, n(%) | Female 11 (46%) Male 13 (54%) |
Age Range, n(%) | 41–50, 1 (4%) 51–60, 4 (17%) 61–70, 6 (25%) 71–80, 5 (21%) 81–90, 5 (21%) > = 91, 3 (12%) |
Diagnoses, n(%) | Cancer 15 (63%) Amyotrophic lateral sclerosis 3 (12%) Cardiovascular/Respiratory 4 (17%) Other neurological 1 (4%) Other (hotel) 1 (4%) |
Current location, n(%) | Hospital 18 (75%) Home 5 (21%) Other 1 (4%) |
European Cooperative Oncology Group Functional Status, n(%) | 0, 1: 0 2: 3 (12%) 3: 8 (32%) 4: 8 (32%) Unreported/unsure: 5 (20%) |
Preferred location of assisted dying, n(%) | Home 6 (24%) Hospice 1 (4%) Hospital 12 (50%) No preference 3 (12%) Other 2 (18%) |
Preferred route of medications for assisted dying, n(%) | Oral medications 1 (4%) Intravenous 17 (71%) No preference 6 (25%) |
Preferred timing of assisted dying, n(%) | Within one week 10 (42%) One week to one month 4 (17%) Greater than one month 5 (21%) No preference 5 (21%) |
Family member characteristics (n = 17) | |
Gender, n(%) | Male 3 (18%) Female 13 (76%) Declined to answer 1 (6%) |
Age Range, n(%) | 21–30, 1 (6%) 31–40, 0 41–50, 1 (6%) 51–60, 3 (18%) 61–70, 9 (53%) 71–80, 2 (12%) 81–90, 1 (6%) |
Location, n(%) | Ontario, 15 (88%) British Columbia, 1 (6%) Nova Scotia, 1 (6%) |
Relationship to patient, n(%) | Spouse/partner 6 (35%) Child 7 (41%) Sibling 2 (12%) Friend 2 (12%) |
Theme/Subtheme | Suggested practices |
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Process Theme 1: MAID requests | |
Encourage MAID awareness | • Hospitals and clinics which care for patients at high risk of death should have publicly available information about MAID so patients are aware of this option • Awareness efforts should target the general public and families to help prepare them for the possibility their loved ones may choose MAID • Institutions should have clear policies around HCPs bringing up MAID |
Explore requests for MAID | • HCPs should be aware that patients may struggle to bring up MAID, even if they are seriously considering it • Support HCPs in how to recognize and explore requests for a hastened death • Use direct language to acknowledge and explore a patient’s request for MAID |
Facilitate written requests | • Written requests and other paperwork need to be simple and accessible • Assist with completing the written requests and witnessing, to avoid the need for corrections/revisions, and consequent delays in care • Provide contact information for Dying with Dignity which can provide volunteer witnesses, or have institutional volunteers who can assist inpatients |
Move MAID requests forward quickly | • Have clear institutional policy/protocol for referring patients who request MAID • Policies should be supportive of conscientious objectors but mandate rapid referral/transfer of patients so as not impede timely response to MAID requests • Provide a map MAID process to patients so they can keep track of next steps and hold the team accountable for moving the request forward |
Process Theme 2: MAID Assessments | |
Assess in a safe, comfortable space | • Provide an outline of the purpose and content of the assessment • Identify private spaces for assessments, ask the patient where they would like to meet and who they would like to have present • Consider use of videoconferencing/telemedicine, as traveling for an assessment may be a challenge for some patients |
Assessors need to build trust | • Introduce clinicians and their role in the MAID process • Acknowledge the need to build trust, if this is a new relationship • Frame the assessment as a conversation; explain the legal criteria for MAID • Use a conversational manner rather than “checklist” approach to encourage information sharing • Facilitate involvement of clinicians the patient has an existing relationships with (eg. family physician) in the assessment process |
Provide transparent procedural safeguards | • Reinforce that the patient can change their mind or stop the process at any time • Having a portion of the assessment with and without family present to ensure non-coercion; be transparent about the reasons for this • Having two HCPs present for each assessment (eg MD/NP with an allied health member) can be a safeguard for both the patient and HCP |
Provide education | • If the patient is willing, encourage close family members to be present during the assessment, so they can understand the patient’s motivations for MAID • Use the assessment as an opportunity to educate and prepare patients and families; MAID assessors and providers often have the best information on what to expect and prepare for |
Process theme 3: Preparation for dying | |
Getting affairs in order | • Develop a list of tasks to be completed, including estate planning • Involve social workers to assist in these decisions and processes as some families may find making arrangements cathartic while for others is may be burdensome |
Support patient and family reflection | • Prepare patients and families for the emotional nature of the waiting period and acknowledging that complexity of emotions they may be experiencing • Ask and explore what families and patients need to make the most out of the waiting period • Specialist palliative care consultation can provide valuable support |
Monitor patient status | • Identify patients at risk of losing capacity early, and ask patients/families if this is a source of anxiety for them • Explain available options and assess preferences in the event that capacity is lost • For patients at high risk of losing capacity, consider close monitoring or expediting assessments and consent process • Offer to reassess patients who have lost capacity as this may fluctuate • Discuss with patients palliative care options which may best preserve capacity, if MAID is their overriding preference |
Incorporate patients’ spiritual and cultural death practices | • Explore preferences for spiritual/religious counselling is important regardless of stated religious followings • It may be helpful to identify faith leaders from various religions who are supportive of MAID and can “step in” to the role of the patient/family’s usual faith community • Non-religious patients may have other rituals or practices |
Offer organ donation, if potentially eligible | • Use standardized screening process for donation so no more patients are approached than necessary, but all potentially eligible patients are asked • MAID assessor/providers may not be knowledgeable about donation; education may be required • Organ donation organizations should develop toolkits and standard practices to assist MAID assessors, providers, and patients with these discussions |
Process theme 4: Death and aftercare | |
Support patient choices for location, route, and timing of death | • Provide clear information about feasible options regarding where, when, and how the MAID provision will occur • Provide the option of oral MAID provision to have further control only if available and feasible and provider is comfortable providing it • Explore with patients who they wish to have present during the provision; it may differ from family preferences |
Choreograph the assisted death | • Accommodate patient and family requests when feasible, but be honest when some options cannot be done • Take exceptional care to be on time or early as delays in provision are very distressing to some patients and families • Care coordination between locations needs to be planned thoroughly and in advanced to ensure a smooth, confident provision process • Patients having control over their death is important to them • Dignity and independence through control brought by on MAID |
Prepare the family for the patient’s death and follow-up | • Tailor education to the needs and understanding of the patient and family • Ask how much detail families want to know; some value specific information on syringes, colour change, time until heart stops while others may not • Support and brief the family before and after provision • Have a space for patients to gather afterwards without being rushed |
Transcendent theme 1: Coordination | |
Provide continuity of care | • Ask the patient which clinicians they would like involved in MAID • Engage the primary clinical team in the MAID process, including family physicians (if patient is in hospital) and sub specialists, irrespective of the patient’s location • Identify a “most responsible MAID clinician” or MAID coordinator |
Provide education and manage expectations | • Provide multiple opportunities and methods for education, written and verbal • Check for understanding • Ensure that patient and family expectations are clear with respect to eligibility criteria, what assisted dying entails, and how flexible clinicians can be in providing assessments, assisting with preparation for death, provision, and aftercare |
Facilitate access | • Patients may require advocacy from clinicians to overcome barriers to access • Check-in on tasks and next steps to ensure the process continues to move along |
Transcendent theme 2: Patient-centred care | |
Explore previous experiences with death and dying | • Probe for previous experienced with death and dying during assessments to help predict a patient and/or family’s needs throughout the process |
Preserve dignity and privacy | • Provide compassionate care aimed at maintaining an individual’s dignity— what this means will vary between patients and families • Exercise even more than usual caution in keeping MAID information confidential than other personal health information |
Be sensitive to stigma | • Be aware that patients and families may have experienced stigma and may take time to trust even well-meaning clinicians • Anticipate that patients and families will struggle with whom to share information about MAID request and how/when to disclose; support patients to tell their families and friends • HCPs should explore with patients and their family members how they are going to tell and how they are going and offer support for those conversations |
Care for the whole family | • Engage families early and if not involved, explore the reasons why with the patient • Anticipate the complexity of emotions that family members will experience supporting their loved one’s decision for a hastened death • Bereavement and follow-up services should be provided to families, where available |
Themes related to MAID requests
I don’t think I saw any MAID information over at the cancer centre. I don’t think so and it should be there, it needs to be there. (Family member #812)
The initial patient contact when that decision is made is critical. I think the conversation that happened … helped him move his decision making forward.…it’s not about handing somebody a pamphlet and saying, “Here, here’s what it’s about.” (Family #512)
“Right. If my doctor didn't want me to do it, then he should have referred me to somebody else. He should have just not said, you're not eligible. And to my way of thinking he was saying, just keep on suffering. Because I was…(Patient #821)
“Because I think most situations, or at least in mine, drawing the process out may cause a lot of undue stress and frustration.” (Patient #421)
Themes related to MAID assessments
[The assessments] both happened at the hospital. There was a really nice quiet room and they were pleasant. It was a conversation.. It was like having dinner with somebody without the dinner and very calm, no pressure … (Family member #812)
“I just wanted to give as much information as I could to persuade them that this was the right thing for me”(Patient #411)
They kept asking her if she wanted to change her mind. And that's a good thing, because it always gives her the opening. And they asked us if we wanted her to change her mind. And we all basically said, no it's her decision whether she wants to go.(Family #822)
“I liked that when I was present at the assessment and I was there to support my sister, I liked that I got sent out so they could interview her alone to make sure that she was not being unduly influenced” (Family member #412)
The second interview, you know, [provided] a bit more detail about how it would actually be handled on the day, the injections and that type of thing. So, more general information that just gave me more information and made me relax more. (Patient #411)
Themes related to preparation for dying
If your life is scheduled and you’re given a timeframe to work with, you do the estate planning and settlements. I think that type of planning makes death a whole lot easier. (Family member #712)
Investigator: What makes the time between now and your death meaningful to you? Participant: Well, nothing. I wouldn’t say it was meaningful. The human instinct is to live as long as you can. It’s in there. You don’t know when it comes down to be your turn to die. As I said to my daughters even now, I’m dying to live but I’m not living to die.”(Patient #631)
You go up and down like an elevator, you know. Do I really understand this? Am I doing the right thing, and my family doing the right thing? Yeah, it's an elevator ride up and down, up and down. They just took all the fear away. I haven't been afraid of anything for the last couple months.....just a belief in what this program offers. I want it to get better but I like it the way it is so far. (Patient #911)
She was happily surprised that she was further along to setting that date.....I think part of that was she was really worried she wouldn’t be competent to… You know, like it would be taken away from her. (Family #412)
Oh I wish I was gone tomorrow…. But ten days. That’s a punishment. What for? I wasn’t that good a boy but that bad I wasn’t either. I’m lying here all day long waiting and waiting for the day to be over. And it’s a long, long day, you can believe me. When you wait for something. (Patient #521)
They offered me spiritual advisors, social workers, whatever I wanted. And they would assist me to get in whatever I needed if I wanted and I basically turned them down. I felt my belief system, my internal setup was secure and at peace with the decision I was making so not an issue. (Patient #411)
I think it’s a really good opportunity because most people, or a lot of people may feel that in choosing MAID it’s a very selfish thing to do. And this sort of helps balance that.(Patient #421)
Themes related to death and aftercare
I think it’s enviable being the author of your own last chapter, as it were. Not everybody has that opportunity to make that decision. (Family member #912)
He is the man for the job.....He knew exactly what he was doing and he knew exactly what to say and he knew exactly what to expect from people. We were totally happy and impressed with him. He just was totally on top of his game. He knew exactly, you know, what to say and do. (Family member #712)
He made a noise after the first one that sort of all surprised us....Just a snoring noise sort of....That was a surprise to all of us. We sort of weren’t sure what was happening. Maybe mentioning something like that, you know, could happen. Then you don’t feel so thrown off at that point. (Family member #232)
Two transcendent themes: coordination and patient-centred care
I have to say, I never expected that level of kindness and cooperation, and information. It's like an information highway. You want to know something, we’ll tell you, just ask. .(1–1-009)
…we could laugh and joke and play music and, you know, have a little chat with all the team members and they were all absolutely amazing.... because the team was so compassionate and warm and friendly… (Family member #632)
I can see it in their eyes. It's not… It's not pity. It’s ‘how can we help you?’ What do we need to do to make it better. (Patient #911)
Investigator: What was the most important thing that the healthcare team could do to help patients?
Participant: Look after my family. (Patient #131)
I'm fully behind this whole program, I hope that it has continued success and that a lot more people are able to take advantage of it...Yeah, it would have been nice to have another couple of weeks, maybe a couple of months even, who knows, right but it wouldn't have been any fun for her and she'd already made up her mind that she did not want any part of that I respected that decision and I was at peace with the whole process (Family member #912)
I think that perhaps counselling could be a bigger part. I was lucky I had it, but I don’t know what you provide for MAID normally. I would think that counselling either for… also for family members. If my husband had say still been alive…I think he would have required counselling to… to face it. (Patient #141)
I’ve had a conversation with one of my physicians here and, for him, ethically, religiously was a hard thing for him to do and he couldn’t condone it. But after talking with me, it has turned his head around to a better point of thinking that he would not want to endure this if it was this way. And all I can say is… try to put the shoe on the other foot. (Patient #811)