Canada’s changing laws about medical assistance in dying (MAID) continue to create morally complex situations for nurses, a recent study from the University of British Columbia says.
Nurses are often the first health-care professionals that patients turn to with questions about MAID, says Barbara Pesut, lead author of the study and a nursing professor at the university’s Okanagan campus.
Many nurses, particularly in palliative care, struggle to accept MAID as part of the health-care system.
“One of the fundamental principles of palliative care is that we won’t postpone or hasten death,” said Pesut, who holds a research chair in palliative and end-of-life care. “[MAID] is definitely hastening [death].
“It really does take palliative care providers some time and some thought to make that philosophic shift.” Pesut is a member of the Canadian Association of MAID Assessors and Providers but not a MAID assessor or provider herself.
Often there has been a “lack of awareness of how critical nurses are in the end-of-life experience,” said Valerie Grdisa, CEO of the Canadian Nurses Association.
Conversations about MAID can create “difficult tensions” for nurses, she says. Professionally, nurses may need to tell patients about all their legal options, but nursing is about promoting life.
Vulnerable populations
MAID use has expanded rapidly, with nearly 45,000 MAID deaths occurring in Canada since it was legalized in 2016. A report released last week by the think tank Cardus says Canada’s MAID regime is the world’s fastest-growing assisted-dying program. The rapid increase in its use has dramatically exceeded government projections, the report says.
Nurse practitioners provided MAID in nine per cent of all MAID deaths in 2022 and seven per cent of all written second opinions, according to Health Canada data.
Not all nurses are comfortable with Track 2 MAID, which is for sick or disabled people who are suffering but whose deaths are not reasonably foreseeable.
One of their biggest concerns is whether Track 2 MAID requests are being driven by social and economic inequalities, says Pesut. This is a concern many organizations, including the Canadian Human Rights Commission, have raised.
Some of the 35 registered nurses and nurse practitioners interviewed for the UBC study expressed concern about people being found eligible for MAID even if their request was motivated by a lack of available home care. Some questioned if disabilities such as vision loss or hearing loss caused by stable medical conditions, should make patients eligible — even if they are suffering.
Study participants raised significant concerns with allowing MAID solely for mental illness because of significant gaps in available mental health support. The study was conducted before the government decided in January to delay allowing MAID for mental illness until March 17, 2027.
“Many felt it was unethical to provide access to MAID when access to mental health treatment was unavailable,” the study said.
Bedside conversations
Nurses are becoming more comfortable with some parts of MAID, particularly having discussions with patients about it, the study says.
After MAID was legalized, many nurses did not know if participating in such conversations ran afoul of criminal law prohibitions on encouraging suicide, Pesut says. Now, many nurses have shifted their focus from avoiding personal risk to determining what the patient wants.
Sometimes, when patients say they want to die, they are expressing pain or frustration, the study says. They do not actually want MAID. Nurses need to be able to determine what the patient really wants, Pesut says.
“It requires a very high degree of skill to have those conversations at the bedside to find out what it is behind these statements,” she said.
Many study participants said it was best not to raise MAID when someone is already vulnerable. For example, when someone has received a new diagnosis, learned their condition is worsening or been admitted to palliative or long-term care.
Mentioning MAID at those times “could send the wrong message to patients during a time of vulnerability,” the study says.
Patients have also raised concerns about having multiple health-care providers ask them if they want MAID, study participants noted. Pesut says this happens because medical records are not easily shared across health-care systems. It would be better if patients have advance-care plans that travel with them.
Nurses can refuse to follow medical orders for any procedure for a variety of reasons, including having personal moral objections or lacking confidence in their ability to perform a procedure properly, says Grdisa at the Canadian Nurses Association. If nurses feel a procedure is not within their scope of practice, regulations require them to seek out professionals who can practise in that area, she says.
There needs to be respect in health-care environments, both for the desires of the patients and the nurses, she says.
“We’re respecting the patient’s choices, but we also have to understand and respect where our nursing colleagues, or any colleagues, are at with these very sensitive decisions and choices,” she said.
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