E-Survey of Stressors and Protective Factors in Practicing Medical Assistance in Dying

Abstract

Objective:

To better identify, quantify, and understand the current stressors and protective factors reported by Canadian medical assistance in dying (MAiD) assessors and providers to inform policy, education, and supports.

Methods:

E-survey of MAiD stressors (n = 33) and protective factors (n = 27); resilience measurement and comments relating to practice involving physicians and nurse practitioners who provide MAiD services and belong to the Canadian Association of MAiD Assessors and Providers or a francophone equivalent. The survey was conducted, while Parliament was considering changes to MAiD eligibility criteria, which occurred during COVID-19 pandemic restrictions.

Results:

In total, there were 131 respondents (response rate 35.8%). Two possible changes to future eligibility (mental disorders as the sole reason for MAiD and mature minors) were highly scored as were extra clinical load and patients' family conflict over MAiD. Twenty percent of respondents considered stopping MAiD work. The CD Resilience Scale-2 mean score was 6.90. Highly scored protective factors included compassionate care, relief of suffering, patient autonomy, patient gratitude, feelings of honor, privilege, and professionally satisfying work.

Discussion:

The identified stressors and reasons for considering stopping MAiD work indicate needs for policy, education, and supports to be optimized or developed. Respondents showed high resilience and highly scored protective factors, which should be optimized. This survey should be repeated in countries where MAiD is legal to determine stressors and protective factors in MAiD practice, stressors addressed, and protective factors enhanced where feasible in the local context for optimal care.

Background

Medical assistance in dying (MAiD) became legal in Canada in June 2016 with specific criteria (voluntary adults ≥18 years, with capacity to make a decision about MAiD and provide informed consent, eligible for Canadian publicly funded health care services, suffering from a grievous and irremediable medical condition and whose natural death is reasonably foreseeable).¹ MAiD may be implemented by a qualified physician or nurse practitioner by providing a prescription for a lethal quantity of specific drugs to be ingested or administered by an intravenous route to a patient who meets eligibility criteria as certified by two qualified practitioners. Opinion polls show that MAiD has gained acceptance by 86% of the Canadian population by February 2020,² but remains contentious, including among some physicians and nurse practitioners. Conscientious objectors are not required to participate in MAiD but must provide an effective referral to a willing practitioner for this service.

After 4 years of experience, there were a total of 13,946 reported MAiD deaths by the end of 2019 (65% performed by family physicians and 9% by palliative medicine physicians).³ With impeding legislation to remove the reasonably foreseeable natural death eligibility criterion⁴ and a scheduled 2021 review of other eligibility criteria, 2020 seemed a vital time to conduct a survey of the stressors and protective factors of physicians and nurse practitioners who assess and/or provide MAiD. Our aim was to better identify, quantify, and understand the current stressors and protective factors experienced by MAiD practitioners, so that policy, education, and supports could be optimized or developed.

Methods

Peer-reviewed literature on the experience of MAiD assessors and providers was reviewed in January 2020. Several qualitative, but very few quantitative studies were identified. The lack of quantitative data on stressors and protective factors meant that their strength and prevalence could not be determined. Themes in the literature were used by an experienced MAiD assessor/provider to develop a survey with items to be ranked by respondents on a four-point Likert scale of “not a stressor = 0,” “mild = 1,” “moderate = 2,” or “strong = 3,” or “not a protective factor = 0,” “mild = 1,” “moderate = 2,” or “strong factor = 3” for MAiD practice. A nonapplicable ranking was also available.

In February 2020, MAiD legislation was proposed in Canadian Parliament to remove the reasonably foreseeable natural death eligibility criteria, which had been ruled by a Quebec court to be unconstitutional.⁴ This proposed legislation has been highly controversial and is still being debated at the time of writing (mid-January 2021). The final wording of the legislation is not yet established, but individuals with grievous and irremediable medical conditions that cause intolerable suffering but without foreseeable natural death will be eligible for MAiD, with enhanced safety precautions, including a reflection period of 90 days among other safeguards under debate. Individuals who do have a reasonably foreseeable natural death will no longer require a 10 days reflection period, and only one witness will be required for the formal MAiD request.⁴

Other MAiD future eligibility criteria changes will be reviewed in 2021, including mental disorder as the sole underlying medical condition, the inclusion of mature minors and advance requests. The criteria for MAiD for a mental disorder as the sole underlying medical condition or mature minors (under age 18) or advance requests for MAiD (especially for dementia) have not yet been defined. However, if accepted, they are likely to require several additional safeguards. Meanwhile, the Canadian government commissioned the Council of Canadian Academies to write expert reports on the state of knowledge on these three topics. These reports are publicly available at www.scienceadvice.ca. MAiD practitioners have expressed their strong views on many aspects of all of these possible changes to eligibility criteria; consequently four items relating to these eligibility criteria were added to the stressor items in this survey.

When COVID-19 pandemic restrictions were declared in Canada in March 2020, many aspects of clinical practice were altered, including MAiD. To capture this, we added a further survey item ranking stress in the practice of MAiD during the COVID-19 pandemic, along with an option for written comments on this or any other item.

There has been increasing concern about burnout among end-of-life health care professionals with some evidence that resilience may reduce burnout.⁵ Consequently, the Connor-Davidson Resilience Scale-2 (CD-RISC 2) item, which measures the ability to change and bounce back after hardship or stress (on a five-point scale from not true at all = 0, rarely true = 1, sometimes true = 2, often true = 3, to true nearly all the time = 4), was also included in the survey and scored from 0 to 8 as directed by the originators.⁶

All survey items were circulated to 10 experienced MAiD colleagues for content validity and additional feedback. The final questionnaire had 33 proposed stressors, 27 proposed protective factors, and 10 demographic questions.

Respondents were advised that the survey was anonymous, any personal identifiers inadvertently disclosed would be deleted, and only aggregated results would be published. Completing the survey would be considered as their consent, and all data would be nonidentifiable and stored on computers secured by a password. No incentives were offered. The survey was submitted to our institutional Research Ethics Board, which deemed it primarily a quality improvement project and provided a waiver (#20-0471, May 19, 2020) from full review.

The survey was formatted and pilot tested with 10 MAiD providers, then electronically distributed from June 22 to July 15, 2020 (COVID-19, wave 1) by Google Forms to assessor and provider members of the Canadian Association of MAiD Assessors and Providers (CAMAP) (www.camapcanada.ca). CAMAP, a voluntary organization, provides peer support, education, networking, conferences, research, and advocacy for all professionals involved in MAiD, including physicians, nurse practitioners, pharmacists, nurses, administrators, lawmakers, lawyers, social workers, bioethicists, speech and language specialists, counselors, policy makers, and more. Many, perhaps most, MAiD assessors and providers belong to CAMAP. The survey was only sent to CAMAP (online) Forum for Assessors and Providers (n = 290) who provide MAiD services across Canada. A translation of the survey into French was concurrently circulated to members of the Communauté de Pratique AMM Québec (CPAQ), and their comments were back-translated by two bilingual researchers into English for analysis. CPAQ (n = 76) operates for physicians practicing MAiD in the French language in the province of Quebec. Two reminders were sent to both CAMAP and CPAQ members.

Total scores for each stressor factor were calculated by multiplying the number of responses in each ranking by their weighted Likert scores (not a stressor = 0, mild = 1, moderate = 2, or strong = 3), then added for a “total score.” We similarly calculated the total score for each protective factor using Likert weights 0, 1, 2, and 3. The stressor and protective factors were then individually ranked in order of their total scores.

Results

We received 137 individual responses from physicians and nurse practitioners who practiced MAiD, and removed 6 with no responses, for a total of 131 (101 English and 30 French) completed surveys from all Canadian provinces (with the exception of Nunavut, Yukon, and the Northwest Territories), resulting in a total response rate of 35.8%.

The majority of respondents were female, >55 years old, and practiced in communities >500,000 (Table 1). The vast majority of respondents provided MAiD services in various combinations of health care settings (including hospitals, residential or hospice facilities) or private residences. Fewer than 5% had ever provided MAiD services in a correctional facility, funeral home, or hotel. Most respondents were family physicians (51.2%) or palliative medicine physicians (13.2%), and others were scattered across other medical specialties or were nurse practitioners (11.5%). It is likely that some who identified as palliative medicine, emergency, and anesthesiology physicians were family doctors with added training and qualifications (Table 1). Respondents provided MAiD services to a mean of 71 patients (range = 1–500). Seventy-three (55.7%) participants had previously witnessed a family member, partner, or close friend experience a painful death, and this was significantly associated with them endorsing the protective factor “knowing that MAiD is available to me or my family if ever needed” (x², p = 0.02).

Table 1.

Demographics of Respondents

Characteristic	Respondents (%)
Gender
Male	49 (37.4)
Female	82 (62.6)
Other	0 (0.0)
Age
<30	2 (1.5)
31–54	55 (42.0)
>55	74 (56.5)
Province
Ontario	58 (44.3)
Quebec	37 (28.3)
British Columbia	15 (11.3)
Newfoundland	1 (0.8)
Manitoba	2 (1.5)
Saskatchewan	10 (7.6)
Price Edward Island	2 (1.5)
New Brunswick	3 (2.3)
Nova Scotia	2 (1.5)
Alberta	1 (0.8)
Population
<5000	9 (6.9)
5001–50,000	31 (23.6)
50,001–500,000	39 (29.8)
≥500,001	52 (39.7)
Profession
MD	116 (88.5)
NP	15 (11.5)
Your role in MAiD
Assessor	21 (16.2)
Provider	9 (6.9)
Both	100 (76.9)
Medical specialty
Family physicians	66 (51.2)
Palliative medicine	17 (13.2)
Psychiatry	13 (10.1)
Anesthesia	9 (7.0)
Emergency medicine	5 (3.9)
General internal medicine	5 (3.9)
Surgery	4 (3.1)
Other	11 (8.5)

MAiD, medical assistance in dying.

All stressor and protective factors were scored by at least ≥100 of the 131 respondents. Among the top 10 stressors most highly scored were 3 related to eligibility criteria scheduled for review in 2021: mental disorders as the sole reason for the MAiD request, mature minors and advance requests. Other highly rated stressors were extra clinical workload, patient family conflict over MAiD, fluctuating capacity, denial of MAiD, urgent requests, and administrative burden (Table 2). Twenty-six (19.9%) respondents were seriously considering stopping MAiD work (see Table 3 for their multiple reasons).

Table 2.

Stressors in Medical Assistance in Dying Practice

Rank	Stressor	Not factor	Mild	Mod	Strong	Total score
1	Future decisions about mental disorders as a sole reason for MAiD (n = 130)	14	16	32	62	266
2	Decisions about mature minors in the future (n = 126)	26	24	31	36	194
3	Extra clinical workload (n = 129)	17	46	54	10	184
4	Patient's family conflict over MAiD (n = 131)	20	55	38	16	179
5	Determination of capacity or fluctuating capacity (n = 131)	23	54	42	12	174
6	Denial of MAiD for a person related to eligibility (n = 131)	22	49	41	13	170
7	Time pressure/urgent requests (n = 101)	7	40	38	16	164
8	Administrative burden (documentation) (n = 101)	10	36	41	13	157
9	Future decisions about advance requests (n = 129)	46	33	27	21	150
10	Mandatory 10-day reflection period with only two exceptions (n = 131)	38	51	27	15	150
11	Difficulty with IV (n = 131)	38	31	28	17	138
12	Assessing comorbid mental disorders in physically ill patients (n = 101)	19	41	30	11	134
13	Difficulty finding a medical expert in specific conditions (n = 131)	46	38	26	11	123
14	Insufficient personal financial support for MAiD (n = 130)	58	30	24	12	114
15	Difficulties of assessing/providing MAiD during COVID-19 (n = 130)	46	51	21	7	114
16	Determination of reasonably foreseeable natural death (n = 129)	50	52	21	6	112
17	Conflicts with colleagues over MAiD eligibility (n = 130)	47	48	21	7	111
18	Emotional burden (e.g., burnout, etc.) (n = 131)	61	40	22	8	108
19	Possible legal complaints (n = 129)	66	35	18	9	98
20	Supporting grieving relative/partners/friends (n = 131)	60	52	19	0	90
21	Difficulty finding an available colleague to assist in MAiD (n = 128)	68	33	14	9	88
22	Absorbing others' suffering (n = 101)	36	49	10	6	87
23	Lack of training or support (n = 129)	68	38	17	5	87
24	Doubts or regrets about your MAiD decisions (n = 131)	66	47	14	3	84
25	Determination of grievous conditions (n = 131)	73	50	6	2	68
26	Social stigmatization/professional isolation (n = 130)	88	19	13	7	66
27	Supporting other health care staff during/after MAiD (n = 131)	77	44	6	3	65
28	Determination of irremediable (n = 130)	75	45	7	1	62
29	Determination of advanced state of decline (n = 131)	78	44	9	0	62
30	Difficulty obtaining a physical location (n = 130)	71	33	13	0	59
31	Difficulty obtaining medication (n = 129)	79	22	13	0	48
32	Emotional conflict about your role (n = 130)	94	23	8	3	48
33	Sense of failure in your other end-of-life care (n = 131)	96	24	0	3	33

All items scored on a scale of 0 = not a stressor, 1 = mild, 2 = moderate, 3 = strong.

N/A was disregarded in calculating total scores.

N/A, not applicable.

Table 3.

Reasons For Considering Stopping Medical Assistance in Dying Work (n = 26)

	Reason	n (%)
1	Too stressful	8 (30.8)
2	Paperwork/administrative burden	7 (26.7)
3	No community peer support	7 (26.7)
4	Proposed legislation overinclusiveness	5 (19.2)
5	Poor remuneration	5 (19.2)
6	Difficulty finding time	5 (19.2)
7	Strong workplace opposition (religious, palliative, or hospice institutions)	4 (15.4)

Although 97 (74.6%) respondents scored the practice of MAiD during COVID-19 as not a stressor or being mild, 28 (21.5%) scored it as a moderate or severe stressor. Fifty (39.6%) respondents provided optional comments on MAiD practice during COVID-19, which we divided by theme with a selection of illustrative quotes (Table 4).

Table 4.

Common Stressors During Covid-19 Pandemic Restrictions

Impediments to accessing MAiD	“Physicians seem more reluctant to refer, assess and implement MAiD.” (q 18)
Impediments to accessing MAiD	“Many cannot be assessed given quarantine and fear of COVID.” (q 18)
Challenges due to use of personal protective equipment	“Difficulty accessing appropriate PPE was frightening at the beginning.” (q 22)
Challenges due to use of personal protective equipment	“Mandatory clothing and protective measures are dehumanizing.” (q 38)
Urgency	“More cases seem to be very urgent since COVID.” (q 8, 10)
Increased suffering	“Patients are dying in pain when MAiD is not available.”
Increased suffering	“More approved patients die before implementation.” (q 18)
Challenges with hospital/institutional COVID-19 policies	“Very stressful that I am no longer able to bring patients in from home.” (q 2)
	“Variable policies by institution/region are confusing.” (q 18)
	“My hospital now prohibits assessments of outpatients.” (q 30)
Limitations of virtual assessments	“The inability to be with patients for assessment has made the practice more stressful and less satisfying.” (q 26)
Documentation challenges	“Getting request forms witnessed by 2 people; should be virtual.” (q 18)
Documentation challenges	“Difficult access to medical documentation/collateral notes.” (q 22)
Restriction of visitors/support people is inhumane	“Very difficult linked to limitations on people that can be present for MAiD… heartbreaking, inhumane.” (q 41)
Virtual assessments	“Assessments have gone fine (both virtual and in-home).” (q 11)
Virtual assessments	“I have been surprised by the lack of change of my MAiD practice during the COVID-19 pandemic, apart from the introduction of virtual care/video/telephone assessments, which were surprisingly thorough and satisfactory, in my experience.” (q 25)
Ability to provide at home	“Very painful to limit the number of accompanying persons but more acceptable attitude at home, based on number (allowed).” (q 39)

Nineteen of 27 protective factors were highly endorsed with total scores >200, which sharply contrasts with only 1 stressor that received such a high total score (see Table 5 for all protective factors). Highest total scores for protective factors were providing a peaceful death, relief of suffering, enhanced patient autonomy, gratitude of patients, and emotionally and professionally satisfying work (see Table 6 for narrative comments). It is interesting that although institutional, regulatory colleges, malpractice insurance, professional associations, social work, practice leadership, bioethics, and religious supports were seen by some respondents as protective factors, these were the lowest ranked.

Table 5.

Protective Factors in Medical Assistance in Dying Practice (Factors That Help Sustain You)

Rank	Protective factor	Not a factor	Mild	Mod	Strong	Total score
1	Providing compassionate/humane care/peaceful death (n = 131)	0	3	10	118	377
2	Relief of patient suffering (n = 131)	0	3	19	109	368
3	Enhancing patient choice and autonomy (n = 131)	0	4	17	109	365
4	Gratitude of patients (n = 131)	1	7	23	98	347
5	Emotionally rewarding work, for example, honor/privilege in assisting (n = 131)	4	8	18	101	347
6	Gratitude of patients' families/friends (n = 131)	1	10	29	89	335
7	Intellectually and professionally satisfying work (n = 131)	4	19	31	77	312
8	Increased confidence in end-of-life care (n = 131)	3	20	38	68	300
9	Learning to be a better doctor/nurse practitioner (n = 130)	7	18	34	68	290
10	Knowing that MAiD is available to me or my family if ever needed (n = 130)	17	13	23	76	287
11	Your family and/or partner support (n = 130)	6	28	28	66	282
12	Team support/debriefing/discussion with colleagues (n = 131)	9	21	50	48	265
13	MAiD education, learning (n = 131)	11	28	43	49	261
14	Nursing support (n = 131)	9	28	33	55	259
15	Collaborating with colleagues across specialties/disciplines (n = 130)	9	32	40	47	253
16	CAMAP discussions/conferences (n = 127)	13	13	37	55	252
17	Care coordination service (n = 129)	19	20	28	57	247
18	Mentorship (n = 130)	10	27	40	44	239
19	Self-care practices (e.g., meditation, sports, other interests, etc.) (n = 130)	15	32	37	44	238
20	Institutional leadership support (n = 130)	40	21	26	28	157
21	Regulatory college support (n = 129)	45	31	23	26	155
22	Malpractice/legal insurance (n = 128)	39	42	21	22	150
23	Medical/nursing association support (n = 129)	41	33	25	21	146
24	Social work support (n = 131)	34	30	24	22	144
25	Department/practice leadership support (n = 129)	41	30	19	25	143
26	Bioethics support (n = 124)	35	32	18	15	113
27	Discussion with spiritual advisor, religious beliefs or faith (n = 130)	62	22	6	10	64

All items scored on a scale of 0 = not a protective factor, 1 = mild, 2 = moderate, 3 = strong; N/A was disregarded in calculating total scores.

CAMAP, Canadian Association of MAID Assessors and Providers.

Table 6.

Protective Factor Comments

Excellent multidisciplinary support team	“I have been very fortunate to have an excellent multidisciplinary support team, which minimizes the stress I have to deal with personally.” (q 4)
Local community support	“Supportive local community after a huge amount of preparatory presentations.” (q 13)
Health authorities support	“The provision of MAiD is very supported by the health authority who view this service as giving patients whether by palliative support or MAiD the best death possible.” (q 6)
Gratitude	“I am grateful to be able to provide MAiD.” (q 34)
Gratitude	“Best gratifying endeavour of my career.” (q 27)
Antidote to other stressors	“MAiD work causes me the least stress out of all the different types of work that I do. It is an antidote to those other stressors.” (q 28)
Feeling honored/sense of meaning	“My MAiD work has been the most important, satisfying and meaningful activity during my 50+ years as a physician. I am in awe of the courage of these patients and families and they have taught me much about life, suffering and becoming a better doctor. I feel honoured to participate in MAiD.” (q 30)

The majority of respondents, 116 (92%), completed the CD-RISC 2 and had a mean score of 6.90 (standard deviation = 1.25) with no significant gender differences.

Discussion

Stressors

Among the 10 stressors most highly scored by respondents were three related to eligibility criteria under consideration or scheduled for review in 2021. Clearly possible decision relating to mental disorders as the sole reason for MAiD was the most concerning and the only stressor with a total score >200. Both support and opposition to this criterion have been voiced, and the Council of Canadian Academies report did not find consensus among its members. The current lack of guidance on this topic was seen by some participants as problematic. Future decision about mature minors being eligible for MAiD was scored as the second most stressful factor, and this was also contentious. Advance request, also scheduled for 2021 review, was scored the ninth highest stressor, but there is increasing public support, especially for individuals with early dementia. Currently considered by the Senate is the removal of the mandatory 10 days reflection period for individuals who are in fact near natural death (ranked 10th by our respondents) and the removal of the criterion of reasonably foreseeable natural death (ranked 16th by our respondents).

Many other top 10 ranked stressors are not surprising such as extra clinical workload, patient family conflict about MAiD, fluctuating capacity, denial of MAiD, urgent requests, and administrative burden. Some of these stressors are amenable to improvement through better human resourcing and scheduling of MAiD services and streamlining of the administrative burden, which usually involves institutional, provincial, and federal reports for each patient. Patient family conflict over MAiD, capacity determination, and denial of MAiD related to eligibility criteria may sometimes be eased by education, mentoring, and experience; however, these may be stressors that are integral to the MAiD process and must be accepted.

A welcome finding is the 19th ranking of “possible legal complaints” by over half of respondents as “not a stressor”; a marked improvement over initial fears. When MAiD first began in Canada in 2016, assessors and providers were advised to discuss each case with their malpractice insurer to avoid “being charged with manslaughter or sued.” This practice was later abandoned as there have been no criminal charges and a tiny number of coroner inquiries or threatened civil litigations in 4.5 years of MAiD practice.

The 15 lowest ranked stressors with total scores <100 have been described in previous qualitative studies^7–12 and deserve consideration but may partly be context specific.

It was concerning that 20% of MAiD service providers were seriously considering stopping MAiD work (Table 3), a previous qualitative finding.⁸ All stressor items require attention through policy changes and increased support, streamlining of administrative burdens, clarification of new legislative criteria, fair remuneration, amelioration of time pressure, and removal of workplace opposition to legal MAiD practice. Although fewer respondents rated lack of training or support as strong stressors, these will likely become more important with prolonged COVID-19 restrictions and potential legislative changes to eligibility, which they scored as very stressful. A survey by the Canadian Hospice Palliative Care Association recommended increased education and training to providers during and after the MAiD procedure.¹² Consideration should be given to providing MAiD training and supports, especially among family physicians, palliative care physicians, and other specialties most likely to provide this service.¹³

A surprising finding was that only 21.5% of respondents found COVID-19 to be a moderate or severe stressor; however, this may reflect wide regional variations in restrictions. However, prolonged stress from COVID-19 wave 2 and beyond is unknown. Some of the identified stressors could be alleviated by planning for future waves of COVID-19 or new epidemics by designating MAiD as an essential service, establishing visitation policies for the terminally ill in institutions, and allowing virtual assessments and signing of consent forms as recently recommended by CAMAP.¹⁴ Provisions could also be established for assessment of MAiD for ambulatory patients. Increased home provision of MAiD when possible was recommended by several respondents, and recently the Office of the Chief Coroner of Ontario documented a decrease in hospital and long-term care home MAiD deaths and an increase in private residences during COVID-19 restrictions.¹⁵

Protective factors

Protective factors were scored much higher than stressors with 26 of 27 factors having total scores >100. Clearly, the most important protective factor with a total score of 377 was “providing compassionate, humane care and a peaceful death”; a finding in line with two recent qualitative studies, which reported that the deep satisfaction and professional rewards of providing MAiD outweighed the challenges.^16,17 Clearly, respondents feel a great sense of commitment and meaning in their MAiD work as illustrated by their responses and positive quotes, including “I am in awe of the courage of these patients and families and they have taught me much about life, suffering and becoming a better doctor. I feel honoured to participate in MAiD.”

Interestingly, the 11th highest protective factor score “knowing that MAiD is available to me or my family if ever needed” was statistically associated with more than half of our participants who responded affirmatively to “Have you personally witnessed a family member, partner or good friend die a difficult death?” For some assessors and providers, past experience with a loved one's difficult death may be one strong motivator for becoming involved in MAiD practice and in finding personal meaning in this work.

Impressively, the CD-RISC 2-item mean resiliency score was very high (6.90) among MAiD service providers. Indeed, this score was significantly higher than a 2017–2018 study of 5445 American physicians whose mean CD-RISC 2 score was 6.49 (p = 0.009, 95% confidence interval = −0.08 to 0.56) and 5198 American working population whose mean score was 6.25.¹⁸ Given that so many of our respondents reported strong protective factors, one possible explanation for the high resiliency scores may be that these play a strong role in building resilience.¹⁹ Or conversely, inherently resilient health care professionals agree to provide MAiD services. A recent systematic review of resilience in palliative care professionals found resilience to be a facilitator in preventing burnout.²⁰

Strengths/limitations of the study

This survey study has several strengths, including the broad response from across Canada, the fact that it provides the first quantitative measures of various stressors and protective factors in Canadian MAiD practice and one of very few internationally, thus serving as a baseline. The inclusion of qualitative comments allowed a fuller understanding of respondents' experiences and emotions.

A limitation to the generalizability is the response rate of 35.8%, which may have been impacted by COVID-19 work changes and increases, the redeployment of some MAiD assessors and providers to off-site locations where they did not have access to their hospital email, as well as summer holidays. We are also aware that a small number of respondents, who were not current members of CAMAP or CPAQ, received the survey through personal contacts with members. As we do not know their exact number, this may slightly lower the response rate. Another limitation is that most respondents were members of CAMAP or CPAQ, which offers practical support to MAiD practitioners and which likely provided a higher comfort level, more social support, fewer stressors, and stronger feelings of meaning toward MAiD. We suggest that this survey be administered again in the future, to determine any changes after legislative changes to the MAiD eligibility criteria are enacted and after the COVID-19 pandemic.

What this study adds

While this work was conducted in Canada, the results add to an international knowledge base of the stressors and protective factors of MAiD (physician-assisted death) practitioners. Health care policy makers and educators internationally where MAiD is legal should consider these findings applicability to their own jurisdiction and consider conducting similar surveys to inform quality improvement, and enhance practice and patient care.

Conclusions

MAiD posed many challenges for MAiD assessors and providers, as well as for patients and their families, which were likely exacerbated by upcoming legislative changes to eligibility criteria and COVID-19 pandemic restrictions. However, physicians and nurse practitioners who assessed eligibility and provided MAiD strongly endorsed many more protective factors than stressors. They also identified some challenges, which indicated the need for quality improvement in policy, education, and supports to be optimized or developed. Policy makers at all levels and health care educators and providers internationally, where MAiD is legal or being considered, need to consider respondents' ratings and comments and attempt to ameliorate where possible and applicable, the stressor issues and enhance the protective factors identified. Our respondents illustrated not only the challenges but also the impressive resilience and commitment of MAiD service providers.

Ethical Approval

Waived. #80-0471 May 19, 2020.

Footnotes

Authors' Contributions

D.E.S., the lead author, is a MAiD assessor and a researcher, a psychiatrist and previous family physician, originated the project, did the literature search, developed the first draft of the survey items, oversaw the project and wrote the first draft of the article. P.V., a francophone family physician specializing in palliative care and MAiD in Quebec, contributed to the items, translated them into French, electronically distributed them to francophone colleague members of CPAQ, and contributed to the write-up. O.M., a BSc student at University of Toronto, formatted the items in the survey, clarified any ambiguities, helped with the French translation and analyses, tables and write-up. P.K., a nurse practitioner at University Health Network and a MAiD assessor and provider, contributed to the items, assisted with the ethics submission, and provided critical edits to the write-up. J.D., a psychiatrist, MAiD assessor, and researcher on MAiD, assisted with developing the items, provided vital content and edits to the write-up. E.R., a UHN research assistant, helped with the formatting of items, tables and edited the write-up. All authors approved the final version of the article.

Funding Information

No funding was received for this article.

Author Disclosure Statement

No competing financial interests exist.

References

An Act to amend the Criminal Code and to make related amendments to other Acts (medical assistance in dying). https://www.parl.ca/DocumentViewer/en/42-1/bill/C-14/royal-assent. (Last accessed August 19, 2020).

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