“The whole culture of death and dying in Canada is changing with MAiD…..”
“My experience is that MAiD work is intimate and sacred………”
Medical Assistance in Dying (MAiD) can bring up unique experiences and challenges for healthcare providers. It is helpful to have some understanding of the processes to determine eligibility for MAiD in order to help patients and families navigate their way. You may be wondering how palliative care and MAiD can work together or you may be considering becoming a MAiD practitioner yourself. If you do not agree with MAiD, you may be wondering about your professional obligations. While this article and accompanying videos are specific to you as a healthcare provider, we recommend you also explore the other articles and videos in this series.
MAiD is legal in every province and territory but there may be differences in availability and specific processes across the country. A local contact person or telephone service will help individuals connect with MAiD providers/teams.
It is not uncommon for those approaching end of life to express a wish to die. This can be related to their suffering in all its domains – physical, psychosocial, and spiritual/existential. Addressing a person’s suffering is a way to explore their desire to hasten death.
These are delicate conversations that, like all conversations about death and dying, require active listening, empathy, openness, and honesty. First and foremost, acknowledge how the person is feeling, and then begin to explore what is behind the feelings.
It is important to clarify whether a person is expressing their desire for an assisted death or expressing their thoughts and emotions regarding the circumstances they are in. When suffering is appropriately addressed, the wish to seek MAiD may or may not pass.
Healthcare providers need to know and follow their professional regulatory body’s advice about discussing MAiD with patients. Individual workplaces may have specific MAiD-related policies and procedures.
Generally speaking, palliative care programs in Canada are not offering MAiD as part of their services. However, there are physicians and nurse practitioners who work within a palliative care program and also provide MAiD. There are some palliative care units and hospices that do not allow MAiD, but there are also many that do.
Palliative care programs continue to provide palliative care to patients who choose to have MAiD throughout advanced illness, death, and bereavement.
As part of the eligibility assessments, MAiD practitioners assess for any unmet needs. The federal law requires that MAiD practitioners ensure that anyone requesting MAiD is informed of all treatment options available, including palliative care. MAiD practitioners may request involvement from the palliative care team to address an issue or a symptom which is contributing to the person’s suffering. If a palliative care practitioner or program is already involved, they should continue to provide services. Good communication between all healthcare providers is essential to fully support the needs and wishes of the person and their family.
In Canada, all deaths are recorded and reported to the Vital Statistics registrar of each province or territory. Provinces and territories are responsible for determining how information is recorded on death certificates, and different approaches to a medically assisted death have been adopted.
As of November 1, 2018, the federal regulations for the monitoring of MAiD require physicians, nurse practitioners, and pharmacists to provide information related to requests for, and the provision of, medical assistance in dying.
Provincial and territorial Ministries of Health may also have reporting obligations. Check with your professional regulatory body.
- Guidance of reporting on medical assistance in dying - Government of Canada
It can be difficult to begin a discussion with a patient on why they have chosen not to tell their family or those closest to them about their decision to have MAiD.
As with any difficult discussion, it is important to listen actively, without judgement, and with the goal of helping the person make as informed a decision as possible. Understanding the nature of the relationships within the family, and whether family has always or rarely been open with each other, can be helpful. For example:
- Is there an issue of trust, i.e., telling someone in the family means “everyone” will know?
- Is the person worried about being judged – that they are doing something “bad” or “wrong”?
- Are family’s spiritual or religious beliefs a concern?
- Is their worry that family will try and “talk them out of it” or that it will result in an argument?
- Is there worry that it will be too emotionally painful for the family to know?
It might be helpful to explain that having family informed and involved:
- Allows the family to hear why the person is thinking about an assisted death and the ways in which they are suffering, which can lead to greater understanding of why the person is exploring MAiD.
- Helps family understand what is involved in the process, including what happens at a medically assisted death.
- Can open conversations about who the person would like to have present at their death and who would like to be there.
- Allows MAiD practitioners to develop trust and rapport with family.
- Helps family witness the safeguards in place to ensure this is the person’s own choice.
Telling family sooner, rather than later, gives them a chance to “catch up” with what the person may have been thinking and feeling for a long time. Sometimes the person may be trying to “protect” their family from further emotional pain, but they may not have thought about unintended consequences, such as family not having time to process what’s happening or feeling hurt, angry or “left out”.
Consider offering to help the person tell their family but ensure they know that ultimately it is always their decision whether to involve or tell anyone about their decision. It may be helpful to engage additional members of the care team, such as a social worker or counsellor to help explore these issues.
It is important to clarify with the person in advance what, if anything, they want the family and next of kin to know after they have died, and what the death certificate will say.
If they give permission that you can explain they had MAiD, it may then be important to explore whether they also give permission to tell family why they did not want them to know beforehand, and why they wanted MAiD. They also need to be made aware that it may not be possible to maintain complete confidentiality regarding the manner of their death after they die.
Not all healthcare providers are comfortable with MAiD. If a workplace supports MAiD, and the healthcare provider does not, federal legislation recognizes, supports, and respects an individual’s right to not participate.
Heathcare providers, however, are required to ensure an individual who may be eligible for MAiD has access to information and willing practitioners. Non-participating physicians and nurse practitioners have a “duty to refer” or a “duty to make an effective transfer of care” to another provider or care coordination service when they conscientiously object to MAiD.
Healthcare providers must continue to provide ongoing non-MAiD-related care to that person, including palliative care, regardless of the person’s wish to explore or have MAiD. Check with your profession’s regulatory bodies to ensure you understand your professional obligations.
The legalization of MAiD in Canada is still relatively new. Whenever there is a difference of opinion, it can be emotionally charged, and relationships can be strained. If you have made your support (or opposition) to MAiD known, you may notice a change in your colleague's attitudes towards you.
Depending on the relationship, you might choose to open a conversation with your colleague by saying that you have noticed their behaviour or attitude towards you has changed (be specific about the behaviour), that the relationship is important to you, and ask if you can talk about it.
You may agree to disagree, but differences of opinion, whether about this or other issues, should not get in the way of good working relationships. On a personal level, working through these emotions and relationships takes energy. You will benefit from a good supportive network. It can be helpful to reach out to your professional association’s psychosocial support services, or your employee assistance program.
The Canadian Association of MAiD Assessors and Providers (CAMAP) provides peer support, education, and research, and contributes to national standards for MAiD. Their website has information and resources to support the role of MAiD practitioners and team members and they have several online platforms where MAiD practitioners (both assessors and providers) can connect with one another.
To connect with MAiD practitioners in your area, reach out to your provincial or territorial MAiD office.
Most MAiD practitioners agree that it would be very difficult work to do in isolation. Working as an interdisciplinary team, as in all of healthcare, brings different perspectives, training, and skills. These perspectives can be invaluable to supporting the entire MAiD process. In addition, a team approach provides the opportunity to work through complicated situations together, to debrief together, and to provide ongoing support of each other. In addition to a physician or nurse practitioner, nurses, social workers, and spiritual care providers can be very helpful with:
- Psychosocial issues.
- Preparatory planning.
- Supporting family before, during, and after an assisted death.
- Pre-briefs and debriefing with the team and others who have been caring for the person.