Elsevier

Geriatric Nursing

Volume 39, Issue 4, July–August 2018, Pages 393-399
Geriatric Nursing

Feature Article
Nurses' perspectives on whether medical aid in dying should be accessible to incompetent patients with dementia: findings from a survey conducted in Quebec, Canada

https://doi.org/10.1016/j.gerinurse.2017.12.002Get rights and content

Abstract

We conducted a survey in a random sample of 514 Quebec nurses caring for the elderly to assess their attitudes towards extending medical aid in dying to incompetent patients and to explore associated factors. Attitudes were measured using clinical vignettes featuring a hypothetical patient with Alzheimer disease. Vignettes varied according to the stage of the disease (advanced or terminal) and the presence or absence of a written request. Of the 291 respondents, 83.5% agreed with the current legislation that allows physicians to administer aid in dying to competent patients who are at the end of life and suffer unbearably. A similar proportion (83%, p = 0.871) were in favor of extending medical aid in dying to incompetent patients who are at the terminal stage of Alzheimer disease, show signs of distress, and have made a written request before losing capacity.

Introduction

Whether euthanasia should be accessible to patients in exceptional circumstances is an emotionally charged issue that raises heated societal and ethical debates in many countries.1, 2 In the scientific literature, euthanasia is usually defined as the administration of drugs with the explicit intention of ending the patient's life at his or her explicit request.3 Euthanasia is legal in a few jurisdictions, including the Canadian province of Quebec since the coming into force of the Act respecting end-of-life care on December 10, 2015.4 Referred to in the Act as “medical aid in dying” (MAiD), this option is currently available to competent adults from Quebec, who are at the end of life, have made persistent explicit requests for MAiD, and have a serious and incurable illness, are in an advanced state of irreversible decline in capability, and suffer unbearably (art. 26). Patients who are no longer competent to make decisions cannot access MAiD through an advance request written while they were still competent (art. 51). However, in March 2017, the Quebec Minister of Health and Social Services announced that a group of experts would be tasked with reflecting on whether MAiD should be extended to incompetent patients who made an explicit request before losing capacity.5 The Minister made the decision to explore this issue after a man was charged with murder in the death of his 60-year-old wife with advanced dementia whose family's request for MAiD had been denied.6

Many nurses are confronted daily with the complexity of end-of-life care, which may include assistance-in-dying requests regardless of their legal status.7, 8, 9, 10 Nurses are often the first healthcare professional to whom patients express – implicitly or explicitly – a desire to hasten their death.7, 11, 12, 13, 14 Nurses may then undertake a variety of tasks, including: talking with patients to uncover the reasons behind their request; informing patients about legal requirements, procedures, and institutional policies regarding assistance in dying; discussing alternative means to relieve patient suffering, including continuous deep sedation; participating in the decision-making process; preparing the administration of euthanasic drugs when the decision has been made to carry out the patient's request; and providing emotional support to families and colleagues after the patient's death.7, 8, 11, 12, 13, 14, 15, 16 Palliative sedation involves the use of medications to relieve refractory symptoms by a reduction of consciousness. Sedation varies from mild to deep, and may be intermittent or continuous. Continuous deep sedation is usually administered to terminal patients whose death is imminent, that is, to patients with a life expectancy of two weeks or less. Palliative sedation and MAiD are both interventions intended to relieve the patient's suffering, but with MAiD the means used to do so is to end the patient's life.17

Debates surrounding the legalization of euthanasia have commonly focused on the ethical and legal responsibility of physicians.1, 7, 8, 14 Voices of nurses are heard less often, despite their daily involvement with terminally-ill patients and their specific expertise in caring for dying patients and their families.1, 10 In Quebec, only physicians are authorized by law to administer MAiD.4 Nonetheless, nurses have a significant role in providing high-quality, person-centered end-of-life care that may involve MAiD. It is thus important to know whether nurses support or oppose broadening legislation to allow MAiD for incompetent patients and what conditions they believe the law should impose.18 Their unique perspective on this controversial issue should be taken in account as it can assist in creating appropriate laws and guidelines regarding end-of-life care.1, 18

The primary aim of this study was to elicit the attitudes of Quebec nurses caring for the elderly towards extending MAiD to incompetent patients, uncover the reasons underpinning their attitudes on this issue, and determine the value they attach to proposed safeguards. A number of sociodemographic and work-related factors may influence nurses' attitudes on this issue.9, 18 Therefore, a secondary objective was to characterize nurses who support extending MAiD to incompetent patients in certain circumstances.

Section snippets

Population and sampling

This study is part of a larger research project investigating the views of various stakeholder groups towards MAiD for incompetent patients, including nurses. The larger project has been approved by the Research Ethics Board of the University Institute of Geriatrics of Sherbrooke (file # 2016-623) and is described in greater detail elsewhere.19 Briefly, regarding nurses, we accessed a random sample of French-speaking registered nurses through their professional association. The sample was

Results

Of 514 nurses invited to take part in the survey, 22 identified themselves as non-eligible and 291 retuned the questionnaire, for a response rate of 59%. Of the 201 non-respondents, 22 returned the non-response questionnaire. Reasons for not taking part in the survey were lack of time (n = 13), never received the questionnaire or lost it (n = 5) or unspecified (n = 4). No nurses replied that they lacked confidence in the anonymity of the data or that items of the full questionnaire were biased.

Discussion

This study gave Quebec registered nurses the rare opportunity to express their views on whether MAiD should be accessible to incompetent patients, and if so, under which conditions. Nearly 60% of sampled nurses took this opportunity, thereby contributing to the current policy discussions about whether incompetent patients should have access to MAiD under certain circumstances. The survey was restricted to nurses more likely to be impacted in their work should the law be changed, that is, those

Conclusions

In conclusion, a majority of Quebec registered nurses caring for the elderly support extending MAiD to incompetent patients in distress who are at the terminal stage of their disease and have made a written request prior to losing capacity. Respect for patient autonomy and previously expressed wishes are major arguments for this support among nurses. Nursing care at end of life is emotionally demanding, perhaps even more so when involving requests for MAiD from patients or patients' relatives.

Acknowledgements

This work was supported by the Alzheimer Society of Canada (Grant # 16-11). The funding agency approved the study design but had no role in the collection, analysis, or interpretation of data, the writing of the report, or the decision to submit the article for publication. We acknowledge the contribution of François Thibeault, PhD, who developed and pretested draft versions of the questionnaire in close collaboration with the coinvestigators. Special thanks are extended to all nurses who took

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  • Cited by (0)

    Conflicts of interest: None.

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