Nurses' perspectives on assisted suicide: Challenges and support needs.

12028 Background: Medical assistance in dying (MAiD) was legalized in Canada in 2016. Cancer accounts for 60-70% of MAiD cases, though little is known about the demographic profile, cancer diagnoses, and treatments received in patients with cancer who pursue MAiD. We reviewed all patients with cancer who underwent MAiD through a large regional MAiD program, in order to better understand this population and identify gaps in the current system of care delivery. Methods: All patients with cancer who received MAiD through the Champlain Regional MAiD Network (CRMN) from June 1 2016 – November 30 2020 were reviewed. The CRMN provides the majority of MAiD services covering a population of 1.3 million in Eastern Ontario. Baseline demographic factors, diagnostic information, and treatment details were collected by retrospective review. The primary endpoint was the proportion of patients with an oncology consultation prior to MAiD. Results: During the study period, 255 patients with cancer underwent MAiD. Baseline characteristics included: median age at death 71 (range 31-100), 51% male, 56% married/common-law. The most prevalent solid tumors were gastrointestinal [GI] (n = 77, 30%), lung (n = 47, 18%), and genitourinary [GU] (n = 35, 14%). Most patients (n = 201, 79%) had metastatic disease at the time of MAiD. Of those without metastatic disease at time of death, common tumor sites included central nervous system (42%) and head and neck (23%). The majority of patients (n = 229, 89%) had seen an oncology specialist prior to MAiD; 226 (88%) had seen a systemic oncologist (medical, hematologic, or gynecologic oncologist), and 189 (69%) a radiation oncologist. Seventy-three percent of patients were followed by a systemic oncologist within 90 days of MAiD, and 44% within 30 days of MAiD. At least one line of systemic therapy was received by 159 (62%) patients, 138 (54%) received radiotherapy, and 61 (24%) best supportive care alone. Median time from last systemic therapy to MAiD was 85 days, and from last radiation therapy to MAiD was 137 days. Palliative care assessed at least 213 patients (84% [8% unknown]). Common reasons for pursuing MAiD included disease-related symptoms (33%), fear of future suffering or disability (19%), and ability to control the time and manner of death (17%). Among 26 patients who had not seen an oncologist, median age was 84 (range 61-100), 77% male, 42% GI primary / 19% GU / 15% lung. Most had seen a palliative care specialist (n = 23, 88%), and in the remaining 3 patients palliative care involvement was unknown. Conclusions: MAiD is a relatively new option for patients with cancer in Canada. The vast majority of patients with cancer who pursue MAiD are diagnosed with advanced/incurable disease, and most have met with an oncology specialist. As cancer treatments become more effective and more tolerable, collaboration between oncologists and MAiD providers is required to ensure patients are well informed of treatment options prior to MAiD.

“Reflection and soul searching”: Negotiating nursing identity at the fault lines of palliative care and medical assistance in dying

IntroductionCanadians have had legal access to medical assistance in dying (MAiD) since 2016. However, despite substantial overlap in populations who request MAiD and who require palliative care (PC) services, policies...

As laws legalizing physician-assisted suicide gain ground

Background: Medical Assistance in Dying (MAiD) and palliative care are often portrayed as oppositional practices due to the belief that the former hastens death while the latter focuses on life-affirming approaches to symptom management. As Canada’s MAiD program expands, the shared focus on end-of-life care raises the question of whether this divide in provision should proceed or if integration of MAiD with palliative care is possible from the perspective of clinicians. Objective: The objective of this study is to explore Ontario palliative care physicians’ perspectives on the potential integration of MAiD within palliative care services. Design: This study utilizes a qualitative descriptive study design. Setting/Subjects: Seventeen palliative care physicians practicing across Ontario were interviewed from February to May 2025. Six abstained from involvement with MAiD, seven acted as assessors and providers, and four acted as assessors only. Measurement: Virtual semi-structured interviews and thematic analysis to identify dominant patterns and beliefs. Results: Our data analysis spanned four main themes: (1) ethical interpretations of the act of MAiD as determinants of inclusion or exclusion, (2) integration versus separation of MAiD and palliative care, (3) MAiD as patient-centered care, and (4) potential negative consequences of MAiD integration. Conclusion: Participants offered varying opinions on the ethical appropriateness of offering MAiD through palliative care, yet all acknowledged the importance of respect for patient choice and provision of a full range of medical treatments for high-quality patient care. Findings highlight the need for nuanced policy and supportive professional environments as palliative care clinicians navigate this ethically complex terrain.

ObjectiveTo examine how Canadian newspapers portrayed physicians’ role and medical assistance in dying (MAiD).DesignQualitative textual analysis.SettingOnline and print articles from Canadian French and English newspapers.Participants813 newspaper articles published from 1972...

BackgroundThe potential legalisation of physician assisted suicide (PAS) in the UK has become a hotly debated issue in recent years. Objections from the palliative care community have hitherto been largely...

Les patients québécois peuvent légalement obtenir une aide médicale à mourir s’ils sont aptes à donner un consentement éclairé, atteints d’une maladie grave et incurable, en fin de vie et ont des souffrances qu’ils jugent intolérables. Depuis l’arrêt Carter (2015) de la Cour Suprême du Canada, l’accès, sous certaines conditions, à l’AMM est même devenu un droit constitutionnel. Les médecins québécois sont ainsi maintenant susceptibles de recevoir des demandes d’AMM de leurs patients. Les lois québécoise et canadienne reconnaissent aux médecins un droit à l’objection de conscience, mais le droit est contesté tant dans les écrits en éthique médicale que dans le débat public. L’article présente les résultats d’une étude qualitative menée auprès de vingt médecins québécois qui n’ont pas intégré l’AMM à leur pratique médicale en raison de leur opposition ou ambivalence à l’égard de l’AMM. Les entrevues visaient à explorer les raisons – religieuses et séculières – expliquant l’opposition ou l’ambivalence par rapport à l’AMM. Les raisons séculières exprimées par les participants ont ensuite été regroupées en quatre catégories et analysées. Les quatre catégories sont : 1) Finalités de la médecine et identité professionnelle, 2) Philosophie de la médecine palliative et allocation des ressources en soins palliatifs, 3) Paternalisme bienveillant, « bonne mort » et intérêts du soi futur, 4) Risque de la pente glissante et protection des personnes vulnérables.

In Germany, palliative care has developed rapidly since the establishment of the first palliative care unit in 1983. More improvements in patient-centered care are only possible if legal requirements as well as education of physicians, nurses, and other professionals involved in palliative care are adapted to current needs. This paper provides an overview of legal and regulatory requirements including a critical appreciation of their influence on palliative care in Germany. Only recently has medical education in palliative medicine been implemented as an integral part of medical studies at German universities. Starting in 2014, physicians applying for a license to practice medicine will have to provide a certificate of basic training in this field. The challenge in upcoming years will be the establishment and enhancement of comprehensive, standardized, and quality-controlled education at the universities. Only six universities have established chairs for palliative medicine, and it will be essential to not only establish more chairs but also to involve medical students in the development of the education. Only minimal requirements are specified for education of nurses in palliative care in the legislation. However, standardized and quality-controlled advanced training courses are available. This training is frequently requested as a prerequisite for nurses working in palliative care. Only limited education programs exist for other professional groups that are an important part of the palliative care team. In addition to the development of palliative care for inpatients with an increasing number of palliative care units, hospices, and first chairs of palliative medicine, different forms of ambulant palliative care services have been developed. Changes in the legislation have influenced the situation for home care enormously in the last 5years, also making it more complex. With the Law for the Consolidation of the Competition in Compulsory Health Insurance ("Gesetz zur Stärkung des Wettbewerbs in der gesetzlichen Krankenversicherung"), a legal claim for palliative home care has been implemented in the fifth book of the social law in 2007. The ambitious goal of full coverage with comprehensive palliative home care has still not been achieved in most locations. However, after initial negotiation difficulties between palliative care providers and health insurance funds, an increasing number of contracts have been made. As a consequence-in addition to more than 240 palliative care units in Germany-more than one hundred palliative care teams have begun work in the field of specialized palliative home care. Legal regulations for the supply of opioids and other medications for the treatment of patients at home have been adapted recently, thus, facilitating fast and comprehensive medical treatment in emergency situations. Overall, the legislation has been adapted significantly, hence, contributing to improvements for patients requiring palliative care. It remains to be seen whether additional adjustments are required in the future.

Objective Medical assistance in dying (MAiD) is the medical provision of substances to end a patient’s life at their voluntary request. While legal in several countries, the implementation of MAiD is met with ethical, legislative and clinical challenges, which are often overshadowed by moral discourse. Our aim was to conduct a scoping review to explore key barriers for the integration of MAiD into existing health systems. Methods We searched electronic databases (CINAHL, Embase, MEDLINE, and PsycINFO) and grey literature sources from 1990 to 2017. Studies discussing barriers and/or challenges to implementing MAiD from a health system’s perspective were included. Full-text papers were screened against inclusion/exclusion criteria for article selection. A thematic content analysis was conducted to summarize data into themes to highlight key implementation barriers. Results The final review included 35 articles (see online Appendix 1). Six categories of implementation challenges emerged: regulatory (n = 26), legal (n = 15), social (n = 9), logistical (n = 9), financial (n = 3) and compatibility with palliative care (n = 3). Within four of the six identified implementation barriers (regulatory, legal, social and logistical) were subthemes, which described barriers related to legalizing MAiD in more detail. Conclusion Despite multiple challenges related to its implementation, MAiD remains a requested end-of-life option, requiring careful examination to ensure adequate integration into existing health services. Comprehensive models of care incorporating multidisciplinary teams and regulatory oversight alongside improved clinician education may be effective to streamline MAiD services.

Background: Terminally ill patients require palliative care to mitigate suffering but may request medical assistance in dying (MAiD). Chronic pain patients experience psychosomatic disorders and suffering. The MAiD controversy in chronic pain patients requires continual review. This is a study of MAiD requests in a pain clinic. It examined the characteristics of patients requesting MAiD, their quality of life (QoL), and natural outcomes. Methods: This is an observational study of 520 chronic pain patients who received treatment in a pain clinic. Data collection included patients’ age, gender, diagnoses, and QoL scores. QoL scores were collected using the Medical Outcomes Study Short Form 36 Health Survey (SF-36). QoL scores were recorded across the eight domains of physical functioning (PF), physical role (PR), bodily pain (BP), general health (GH), vitality (VT), social functioning (SF), emotional role (ER), and mental health (MH). Results: Five patients (1%) inquired about or requested MAiD. All of them were men aged 43 to 80 years. All patients have neuropathic paraspinal non-cancer pain. QoL scores were monitored over 3 years. The average change in PF was minimal (-0.2 points). PR score showed an average increase of 0.2 points. BP scores showed an average increase of 1.6 points. GH scores increased by an average of 0.6 points. VT scores showed an average increase of 0.6 points. SF scores showed an average increase of 0.6 points. ER scores increased by an average of 0.8 points. MH scores showed a mean increase of 0.8 points. Conclusion: Despite chronic pain and suffering, the study shows these patients maintained stable lives with ongoing value-based pain clinic care. Their pain levels are controlled, ensuring stable mental health and general functioning. Therefore, instead of MAiD, it is ethical and logical to continue providing high-quality pain management and compassionate support. These patients can live with dignity and comfort instead of a premature death.

Physician-assisted suicide (PAS) remains a subject of global debate and ethical controversy, alongside other end-of-life issues such as euthanasia, palliative care, access to health and social care services, and, importantly, patient autonomy. Within this context, PAS is defined as the practice in which a physician, at the explicit request of a competent patient, prescribes a lethal medication that the patient may self-administer to end their own life. This definition clearly distinguishes PAS from euthanasia, wherein the physician directly administers the life-ending drug. Despite ongoing efforts to establish a unified definition, significant variability remains across jurisdictions with regard to eligibility criteria, procedural safeguards, and the overarching legal and ethical frameworks governing PAS. In Italy, there is currently no effective legislation regulating euthanasia or PAS, which remain practices punishable under Articles 579 (homicide of a consenting person) and 580 (instigation or assistance in suicide) of the Italian Criminal Code. The Tuscany Region has prepared a regulatory attempt at the regional level, which has, however, limited itself to proposing an operational protocol that distinguishes the operational responsibilities that the PAS procedure applicant will face. However, following several relevant cases that profoundly influenced the Italian debate, significant attention has been directed toward end-of-life issues.

Whether institutions and not just individual doctors have a right to not participate in medical assistance in dying (MAID) is controversial, but there is a tendency to frame the issue of institutional non-participation in a particular way. Conscience is central to this framing. Non-participating health centres are assumed to be religious and full participation is expected unless a centre objects on conscience grounds. In this paper we seek to reframe the issue. Institutional non-participation is plausibly not primarily, let alone exclusively, about conscience. We seek to reframe the issue by making two main points. First, institutional non-participation is primarily a matter of institutional self-governance. We suggest that institutions have a natural right of self-governance which, in the case of health centres such as hospitals or hospices, includes the right to choose whether or not to offer MAID. Second, there are various legitimate reasons unrelated to conscience for which a health centre might not offer MAID. These range from considerations such as institutional capacity and expertise to a potential contradiction with palliative care and a concern to not conflate palliative care and MAID in public consciousness. It is a mistake to frame the conversation simply in terms of conscience-based opposition to MAID or full participation. Our goal is to open up new space in the conversation, for reasons unrelated to conscience as well as for non-religious health centres who might nonetheless have legitimate grounds for not participating in MAID.

Physician-assisted suicide (PAS) is typically associated with serious physical illnesses that are prevalent in palliative care. However, individuals with mental illnesses may also experience such severity that life becomes intolerable. In February 2020, the previous German law prohibiting PAS was repealed. Patients with severe mental illnesses are increasingly likely to approach physicians with requests for PAS. To explore the ethical and moral perspectives of medical students and physicians when making individual decisions regarding PAS. An anonymised digital survey was conducted among medical students and physicians in Germany. Participants were presented with a case vignette of a chronically depressed patient requesting PAS. Participants decided on PAS provision and assessed theoretical arguments. We employed generalised ordinal regression and qualitative analysis for data interpretation. A total of N = 1478 participants completed the survey. Of these, n = 470 (32%) stated that they would refuse the request, whereas n = 582 (39%) would probably refuse, n = 375 (25%) would probably agree and n = 57 (4%) would definitely agree. Patient-centred arguments such as the right to self-determination increased the likelihood of consent. Concerns that PAS for chronically depressed patients might erode trust in the medical profession resulted in a decreased willingness to provide PAS. Participants displayed relatively low willingness to consider PAS in the case of a chronically depressed patient. This study highlights the substantial influence of theoretical medical-ethical arguments and the broader public discourse, underscoring the necessity of an ethical discussion on PAS for mental illnesses.

For all healthcare professionals, involvement in end-oflife decisions raises the most complex ethical questions. We bring with us, to these discussions, our knowledge of the implications of our actions, our knowledge of the patient and family and an overwhelming desire to ease suffering and comply with the patient’s wishes and needs. Therefore, any paper that helps to clarify thought processes and professional expectations is to be welcomed. The Task Force of the EAPC had an unenviable task in developing a position paper on euthanasia. Not only were they dealing with a subject on which most individuals have a personal view, they were also dealing with many countries that have differing legislation and cultural mores with regard to euthanasia. Because of this, the paper does include some aspects, which while still open to discussion, remain illegal in many parts of Europe. It may also be perceived to be too general to give any specific answers to the questions being asked within healthcare settings. The first point of the position paper clearly identifies the need for the recognition of the various approaches to palliative care across Europe. This point does not say whether this variety is appropriate, which is quite possible, or whether the EAPC is looking for a consensus decision. The use of the modified WHO (2002) version of a definition of palliative care, though, ensures that this paper is clearly grounded in the premise that palliative care intends neither to hasten nor postpone death. This paper is very clear in its discussion as to what constitutes `euthanasia’ and `physician-assisted suicide’. The discussion on the use or `abuse’ of the word `voluntary’ is very instructive and certainly gives voice to a fundamental principle in the debate surrounding euthanasia. How this `voluntary-ness’ will be monitored is of great concern, as it has already raised some concerns in countries where `euthanasia’ is considered an appropriate part of care. It is also clear that euthanasia should never be seen as an alternative to excellent pallia tive care or that it is the role of palliative care health professionals, alone, to make these decisions. We are all aware of situations in which symptom management is seen as the job’ of the specialist palliative care team, when in truth `excellent’ palliative care is the role of all health professionals. The paper clearly identifies that in the presence of excellent palliative care requests for euthanasia may be altered. However, it also acknowledges that requests are very individualized and require acknowledgement and careful attention. One area that will continue to be debated is that concerned with the issue of terminal hydration and nutrition. The position paper states that these should be initia ted when clinically indicated. It does not expand on what `clinically indicated’ really means. And, while it acknowledges that much of the current evidence base for euthanasia and `decision making’ within end-of-life decisions is methodologically suspect and anecdotal, this sentence does little to help professionals when being pressurized by relatives to not let my wife/husband/ mother . . . starve’. The comment on living wills’ also needs further support, as the legal position on these forms of `preplanning’ remains open to challenge. It is important that health professionals are not further compromised in their decision making from the fear of litigation. It is clearly part of any decision making process that the rights of the individual are fully acknowledged. But the health professional needs to be similarly protected so they are not in the position of `dammed if they do and dammed if they don’t’. F inally, my only real criticism, rather than comment, on this paper is based on part of the ethos of the WHO definition of palliative care `Uses a team approach . . . ’. If the EAPC paper is to be truly helpful it needs to acknowledge the involvement of the whole team in this decision making. As such, the thoughts, opinions and processes of a range of health professionals should have been included within the task force. Nurses are the group who may often have the closest relationship with the patient during their palliative care and would certainly form the largest workforce in permanent contact. Nurses are regularly involved in intimate discussions of the beliefs and desires of the dying patient. Their contribution and that of other health professionals to the original development of this position paper may have altered little of the context but would have grounded it in the reality of practice and the tone would have been less medical and reflect a team approach to care. Palliative Medicine 2003; 17: 120