Assisted Dying: Practical Considerations for Hospitals
Even in countries where assisted dying has been legally available for years, the number of assisted deaths remains a small percentage of total deaths. In Belgium and Canada, which have had legal assisted dying for 16 years and five years respectively, assisted deaths make up about 2.5 percent of all deaths in both countries. Despite the low total number of assisted deaths, instituting assisted dying has a large impact on the healthcare system. There are many hundreds of practical questions to address for the system to work well, and, since the specifics of the legislation will affect how best to institute the policy, there is not a uniform approach all places can follow. Nevertheless, there are common issues that arise, and the places can learn from those that have already gone through the transition. Here, we focus on some of the questions hospitals typically face when they decide to offer assisted dying.
Educating Staff and the Public
Even though assisted dying has been legal in Canada since 2016, there are still members of the public who are unaware that it is available. And, while it is getting less common, in the first few years post-legalization it was common for healthcare staff to be unaware that it was available or what to do if a patient asked about it. Therefore, it is important that both healthcare workers and the general public are educated about the availability of assisted dying, what the qualifying criteria are, and how to go about making an inquiry.
A further challenge is that some jurisdictions restrict how physicians can discuss assisted dying with patients. In many places, physicians are not allowed to recommend assisted dying, which can have the effect of discouraging physicians from talking about it at all. All of these challenges make it difficult to strike a balance between informing people of available options and preventing negative outcomes, such as patients trusting their providers less. To our knowledge, there is no evidence of a widespread increase in distrust of doctors post-legalization, yet it is a concern some providers have, and there are isolated reports of patients changing physicians if they find out that the physician participates in assisted dying.
There is no quick fix for this issue, but it is worth reflecting on one’s assumptions and the assumptions of others. With such a big change to a system and with such strong feelings about the change, people are more likely to fall prey to biases, such as the status quo bias, in which people prefer that things stay the same. The assisted dying literature is replete with claims that there will be extremely negative outcomes while providing no evidence for these claims (for one egregious example, see this paper). Of course, it is important to be on guard for negative effects, but we should not base important decisions on minimal evidence. There is no evidence that simply telling people that assisted dying is one option among many is likely to lead to widespread distrust of the healthcare system.
Hospital Organization
There are important questions concerning the process of assisted dying provision in hospital. Here’s one issue an Ontario hospital faced soon after assisted dying became legal in Canada: A local resident went to the hospital intake desk and said that she wanted to be assessed for Medical Assistance in Dying (as it is known in Canada). She had multiple medical issues that would likely qualify her for hospitalization, and she had already seen multiple specialists and had tried some treatment, but it was ineffective. The hospital faced the following question: Where should this patient go? There was no unit for MAiD, and, since she was uninterested in standard care options, the units she would usually be considered for seemed inappropriate. In the end, a solution was found, and it prompted the hospital administration to quickly develop a process for such cases.
That patient’s situation is now somewhat unusual in Ontario, since most people requesting assessment are either already in the hospital or can now access it through the community health system. A related organizational question is where inpatients should receive provisions. In Canada, this has turned out to be a more important question than was first predicted. When asked in surveys, most people say that they prefer to die at home. In practice, people often choose to have their assisted death in hospital, though this is often for logistical reasons instead of overall preference. There is a move in Ontario to build dedicated places for assisted deaths to occur, but such changes take time and will not cover every case.
Hospitals have to decide where provisions should occur. There are two options. The first is for the patient to stay on the unit where they are already receiving care. Logistically, this is often the easiest choice, but there are issues to navigate. The patient often wants loved ones to be present, so they must be accommodated. A greater challenge is maintaining privacy, both for the patient and for other patients and families on the unit, who might be unsettled to know that an assisted death is taking place nearby. This was recently a problem at an Alberta hospital, where a gregarious patient who had a scheduled provision went around the unit telling others in an upbeat way that he was going to die soon. The nursing staff were concerned about the effect this was having on the other patients. Still, most Alberta hospitals take this approach (and it would not be possible to keep such patients away from others).
Another option is to have a dedicated space for provisions. This has many advantages, such as ensuring that the area is private, the room can be decorated to be less clinical, and the family can have more time in the room following the provision. There are also downsides to this approach. An Ontario hospital that chose this option found that the area became stigmatized by staff. They reported feeling uncomfortable going near it, and some even had concerns about ghosts. Eventually, the problem was addressed, but it added work that took away from other priorities.
A final issue about hospital organization is the importance of selecting a person or team to manage these decisions. Just as there is no unit designed for assisted dying, there is no single team or administrator it should obviously fall on. A clinical ethicist can be an invaluable resource if the hospital has one. If not, care should be taken to ensure that someone is responsible for implementing changes and addressing concerns.
Unit Considerations
Since assisted dying is often viewed as a radical departure from how medicine was previously practiced, it is important to give physicians and staff the space to explore their feelings and share their thoughts. In addition to educating staff on assisted dying laws and policies, in Alberta, the clinical ethics service has organized unit meetings for staff. The goal of these discussions is to answer questions and to provide a forum for staff to share how they are feeling. While some staff feel decided about the issue one way or the other, we find that many are unsure how they feel.
Beliefs change. Some find that hearing others’ experiences makes them more willing to assist with a provision themselves. Others find that, once they participate, they no longer want to participate in provisions. Providing these opportunities for discussion improves morale, sets expectations, and prevents inappropriate behaviour, such as discussing the topic on the unit during shifts.
The most successful approach is to give providers the space to act as they see fit. Some will decline to participate through conscientious objection, while others will participate through conscientious provision. Over time, it might be possible to set different expectations, such as requiring that providers taking on a certain role are trained in and feel comfortable participating in assisted dying. For now, the best approach is to let providers decide for themselves. A common approach with nurses, who are needed to support provisions, is to have them let the unit manager know whether or not they are comfortable participating. That way, the unit manager can ensure that the appropriate staff are available for a provision. Staff who participate are frequently given the rest of the day off and are directed to support in case they are required.
Following Others
For many, the legalization of assisted dying marks a dramatic change for healthcare. Whether this change is brought about through referendum or court order, hospital systems and providers must adapt to the change. There are far too many decisions to consider than can be listed here, but, as noted, places instituting legislation can learn from regions that have already gone through the process.
