Canadian nurses have received guidance about discussing medical assistance in dying (MAID) with their patients.
In July, the Canadian Nurses Association released its new code of ethics for nurses. It includes specific references to MAID and a lengthy discussion about end-of-life care.
“This is a modern code for a modern and evolving profession — grounded in compassion, informed by lived experience, and guided by justice,” Valerie Grdisa, the association’s chief executive officer, wrote in the forward. MAID is listed as a particular concern for nurses, along with gender-affirming care, harm reduction, racism, climate change and social justice.
The Canadian Nurses Association represents nurses across Canada. While not every nurse is a member, the code of ethics applies to all nurses.
Nurses need clarity about whether they can discuss MAID with patients, says Sally Thorne, a registered nurse and professor emeritus at the University of British Columbia’s school of nursing who has researched nurses’ experiences with MAID.
“It makes explicit … that patients who are facing an end of life, for example, deserve the right to be able to have those conversations about options for care if they want to,” Thorne said.
Conversations about MAID
Nurses have wondered whether discussing MAID with patients violates Criminal Code prohibitions on counselling or aiding a suicide, says Thorne. The association’s previous code of ethics was published in 2017, shortly after Canada legalized MAID in 2016.
The new code says nurses are to “[work] to relieve pain and suffering, including appropriate and effective symptom management, to allow people to live and die with dignity.”
The new code “provides some clarity … that it is an ethical practice to explore [MAID with patients],” said Thorne.
Nurses may ask patients questions to determine if they are interested in MAID when, for example, a patient asks if there are more medical options to relieve their suffering, Thorne says.
Thorne provided input on the code but did not write it. She is also a research member of the Canadian Association of MAID Assessors and Providers, but not a MAID assessor and provider herself.
Some patients who are interested in MAID may be uncomfortable bringing it up themselves, she says.
“It’s never going to be a tick box that you can say, ‘You’re allowed to say this sentence and not this sentence,’” she said.
“Each case for nursing is different. Each patient uses different language. The conversation comes up in ways you wouldn’t have expected.”
Concerns about coercion
Thorne has worked on research about nurses’ experiences with MAID which documents some patients’ frustrations about being asked multiple times if they want MAID.
Patients should report concerns if nurses bring up MAID in a coercive way or after a patient has said they do not want it, Thorne says.
But just because a patient has previously said they do not want MAID does not mean it could never be discussed again.
“I don’t think there is an obligation [for nurses to initiate conversations about MAID],” said Thorne.
“There is an obligation not to block people from those services to which they’re eligible. And that’s the subtle difference. Failing to go into any conversation about, ‘What can we do for you?’, ‘How can we support you?’, for example, if you don’t go into that, then somebody really may have no path forward.”
A patient’s decision about MAID needs to be respected, she says.
Conflicts of conscience
Only 5.5 per cent of MAID providers in 2023 were nurses, according to Health Canada.
But nurses who are not MAID assessors and providers may still encounter MAID at work. This may occur if patients discuss their end-of-life considerations with nurses, or if nurses assist MAID providers with inserting the IV to dispense MAID medications.
Nurses need to tell their employer if they personally object to MAID so that appropriate alternative arrangements can be made for a patient’s care, the code says.
Some nurses may support MAID in some cases but not in others, says Thorne.
“Nurses may decide if [MAID discussions are] sufficiently uncomfortable for them, that they would transition their work into a different setting, one in which their conscientious objection is not creating havoc.”
The code of ethics also tells nurses to recognize how a person’s social situation and life circumstances can impact their health.
Nurses are concerned about people opting for MAID because of social and economic disadvantages, Thorne says. Multiple organizations — including the Canadian Human Rights Commission and the United Nations — have voiced concern about Canadians with disabilities opting for MAID because of poverty or lack of disability supports.
Thorne says she is hopeful that concerns about people opting for MAID due to social disadvantage will prompt reform “to expand appropriate access to mental illness care and chronic illness care and disability services and all of those aspects [of health care] that have not been equitably managed.”
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