NUR 410 Week 10

Overview of Nursing Role in MAID

• MAID is a recognized end-of-life care option in Canada with medical and legal considerations

Historical Context

• Palliative care was initiated only when the end of life was near
• Primary focus on curative/disease-modifying treatments when death was imminent
• Limited time was allocated for managing symptoms, providing comfort, and offering emotional support

Contemporary Approach

• Palliative care starts at diagnosis while using disease-directed treatment
• Care progressively shifts from curative to comfort
• Support is provided to families even after death during bereavement

Defining MAID

• MAID involves a physician or NP administering a substance that causes the patient's death, at the patient's request
• MAID can also involve a physician or NP prescribing a substance that the patient self-administers, leading to their death, at the patient’s request

What MAID is NOT

• MAID is not a replacement for symptom management, palliative sedation, withdrawal of life support, a solution for actively dying patients or an advanced directive

Legislative History

• Bill C-14 introduced eligibility criteria and safeguards for individuals seeking assistance in dying who had a reasonably foreseeable natural death
• Bill C-7 established a two-track approach and new procedural safeguards for those who did not have a reasonably foreseeable natural death
• Bill C-7 removed requirement for a reasonably foreseeable natural death, broadening eligibility
• Track 1 applies when natural death is reasonably foreseeable, offering fewer procedural safeguards
• Track 2 applies when natural death is not reasonably foreseeable, imposing stricter safeguards

Federal Reporting Mandates

• Medical practitioners, NPs, pharmacists, and pharmacy technicians must report MAID deaths and deaths that don't result from it
• Enhanced reporting responsibilities to Health Canada may include other health professionals reporting cases where MAID occurs
• Data and demographics are collected, including race, indigenous identity, and disability
• Anticipated data analysis of volumes, trends, and inequities in MAID access across Canada

Provincial Reporting Mandates

• Medical practitioners and NPs must report MAID deaths to the Office of the Chief Coroner in Ontario
• Reporting is done through a secure online MAID Death Report
• MAID documents and clinical notes/reports are sent to the Coroner's Office upon request

Requirements for Requesting and Witnessing MAID

• A written request for MAID is legally required
• The written request must be signed and dated in front of one independent witness
• The witness must be at least 18 years old; understand the request for MAID; not benefit financially; not own/operate the facility; and not be an assessor or provider of MAID
• Updated legislation allows paid healthcare workers providing care to act as witnesses, subject to willingness, availability, and employer permission

Eligibility Criteria (Bill C-7)

• To be eligible for MAID, one must be 18+, have decision-making capacity, and be eligible for publicly funded healthcare
• The request must be voluntary, free from coercion or external pressure
• One must have a grievous and irremediable medical condition, meaning a serious and incurable illness/disability, advanced irreversible decline, and enduring/intolerable suffering deemed unacceptable by the person
• Informed consent is required after receiving all necessary information

MAID Eligibility Assessments Explained

• Only a medical practitioner or NP can determine MAID eligibility through a formal assessment based on federal criteria
• Participation in MAID assessments is voluntary
• Two independent assessment opinions are needed
• Assessors must be independent and not in a supervisory or mentorship role
• Assessors may be part of the patient’s circle of care
• Assessors cannot be beneficiaries of the person requesting MAID
• Some assessors only do assessments, while others also provide MAID
• Extra education and resources can be found through organizations like the Canadian Association of MAID Assessors and Providers

Outcomes of Eligibility Assessments

• The care plan is discussed with the provider/clinical team, ensuring continued access to routine care
• Re-assessment by the same assessors may be possible later
• Access to additional assessment opinions, like MAID coordination service, is possible
• With eligibility confirmed, MAID assessors determine if the person has a Reasonably Foreseeable Natural Death (RFND) or Non-Reasonably Foreseeable Natural Death (Non-RFND), determining which track of safeguards apply

Exclusion Criteria for MAID

• Federal legislation excludes cases involving mental disorders alone and mature minors
• Advanced directives are excluded where the person isn't capable of giving consent at the time of MAID unless a Waiver of Final Consent applies

Procedural Safeguards: Track 1 vs. Track 2

• Track 1 involves RFND, no reflection period, potential waiver of final consent, and MAID provision dependent on resources
• Track 2 involves Non-RFND, a 90-day assessment, clinical expertise from the assessor, and consultations from professionals

Key Safeguards for MAID

• Two independent assessments confirm eligibility and a written request signed and dated with a witness are required
• The person has the opportunity to withdraw at any time and must be offered access to palliative care
• Pharmacists must be notified and deaths reported to the Chief Coroner by physicians/NPs
• MAID documents must be submitted to the Coroner, and federal reporting is mandatory
• Express consent is needed at the time of MAID, or you use the Waiver of Final Consent if eligible

Three Types of Consent

• General, express (final), and advanced (waiver of final consent) are the three types of consent for MAID

Consent According to the Health Care Consent

• Patients must understand and appreciate the consequences of their decision
• NPs/physicians ensure patient confirms MAID requests and can withdraw consent
• Applies only if death is reasonably foreseeable
• Patient still has access to MAiD if capacity is lost before the planned date
• Must be in writing and signed

Waiver of Final Consent in MAID

• Bill C-7 introduced the option for a waiver of final consent, allowing for MAID even if capacity is lost
• Waiver applies only to Track 1 patients when death is reasonably foreseeable
• Standard waiver forms available via the Ministry of Health & Long-Term Care website are completed by a MAID provider and patient
• The patient assessed and approved for MAID at risk of losing decision-making capacity before the date, the waiver does not obligate the provider if capacity

Hospital-Based In-Patient MAID Process

• Routine care continues, managed by the MRP and clinical team
• Ensure clear MAID request, facilitate dicussions, and provide support
• Assessment #1 determines outcome, determines capacity, and procedural safeguards
• A written request form needs a witness and declaration criteria
• Assessment #2 to determine outcome, determine capacity, and procedural safeguards
• Provision by person-centred

Social Context of MAID in Canada

• The Government of Canada, Health Canada, Canadian Association of MAID Assessors and Providers, and Dying with Dignity operate and regulate across the country
• The Ontario MAID Coordination Service, Office of the Chief Coroner, Communities of Practice, and Professional Associations and Colleges operate at the provincial level
• In local settings MAID can happen in residences, hospitals, hospice, etc
• Individually, MAID is influenced by personal values and experience, professional roles, and peer support

Themes in Canadian MAID Policies

• Supports with team approach, informed choice, eligibility, safeguards, and conscientious objection
• Law does not allow moral judgements about personal beliefs

Roles and Ethical Considerations

• Educate, support, and comfort patients and families
• Need to insert an IV and act as a witness
• Nurse practitioners and medical practitioners can assess, prescribe, administer, and report
• RNs and RPNs provide optimal care and the level of involvement is based on role
• The Directors, Managers, and Coordinators support operational processes and deliver care
• Lack of clear eligibility criteria creates unequal access
• Conscientious objection can limit access, organizations opposed to MAiD required to post policies
• Stigma is experienced in rural locations
• Discussing with all parties increases awareness

Navigating the "Web"

• Physical, legal and informational barriers
• Dialogue and debate is necessary to continuously assess

Ethical Language and Cultural Values

• Provide dignity through nonjudgemental, non-abandonment and confidentiality practices
• Cultural values acknowledge diverse
• Policies should always be mindful of vulnerability and moral conflicts