Integration of medical assistance in dying into family practice

Case description

A 72-year-old woman presents with a 2-month history of dysphagia. She has not visited a clinic for a few years and appears well. She complains of some acid reflux and difficulty “getting the food down.” After an unsuccessful trial of medications for gastroesophageal reflux disease, you refer her for a barium swallow and a chest x-ray scan. To your surprise, the findings are worrying, pointing to a mediastinal mass intruding on the esophagus. Within a few weeks, she has a biopsy confirming small cell carcinoma of the lung. Computed tomography and bone scan findings come back with concerning results suggesting metastasis. You refer the patient to an oncology specialist and she starts a trial of palliative chemotherapy. However, over the next few months, she experiences weight loss, fatigue, and bony pain. She asks you about medical assistance in dying (MAID). Up until now, you would have referred her to the local MAID coordinating office, but as you are working through the case as a clinician teacher with a family practice resident, you pause. Together, can you consolidate and enhance your understanding about MAID to explain it and start this process with her? You are reminded of the key learning objectives for MAID training established in a mixed-methods study focusing on family medicine residency programs in Canada (Table 1).^1,2

Involvement in assessing patients for MAID enriches clinicians’ capacity for caring. Research indicates the process brings deep satisfaction for clinicians,³ despite the challenges of learning a new approach and the associated administrative burden. Ensuring appropriate information about MAID is provided also requires a comprehensive goals-of-care discussion with the patient and the timely involvement of palliative care.⁴ As of September 2023, a nationally accredited curriculum in both official languages is available in Canada at no cost for physicians and nurse practitioners.⁵ The Canadian MAID Curriculum (CMC) was initiated by the Canadian Association of MAID Assessors and Providers (CAMAP) through a grant from Health Canada and with guidance from the National Steering Committee composed of members from most professional health care associations, including the College of Family Physicians of Canada, the Royal College of Physicians and Surgeons of Canada, and the Canadian Nurses Association. The overall goal of the CMC is to standardize and harmonize the education and approach to MAID of nurse practitioners and medical doctors who assess for eligibility and provide MAID in Canada. Throughout each module, opportunities for clinicians to reflect and improve their resilience are included, addressing the concern that assessing for and providing MAID may trigger questions about values, autonomy, and ethics. To complete the entire curriculum, 27 hours of participation are required: 13 hours of online self-study and 14 hours of facilitated sessions. The CMC was created through a contract with the Queen’s University Learning Management System and now has more than 1000 learners engaged with various stages of the curriculum. Topics 1 (foundations of MAID in Canada) and 2 (clinical conversations that include MAID) are taught through online self-study and provide learners with background about MAID, enabling them to discuss it with patients (Box 1).⁵

Most Canadians support the Supreme Court decision in Carter v Canada that led to the first MAID legislation in 2016.⁶ An Ipsos iSay panel poll was conducted from June 7 to 12, 2023, and a representative sample of 3502 Canadians aged 18 years and older was interviewed.⁷ According to results of this poll, support for the Supreme Court decision is high, at 84%. People older than 55 support it even more strongly, at 89%. Support for it among faith communities is also high, including 83% of Catholics and 79% of Protestants. Therefore, family physicians can expect inquiries about MAID from patients, particularly following diagnosis of an incurable condition or disease.

An assisted death can occur once a person submits a formal request, is found eligible by 2 clinicians, and relevant safeguards are met.⁸ In 2022, most such requests (13,102 [81.4%]) resulted in the administration of MAID.⁹ The remaining 18.6% resulted in an outcome other than MAID: 560 individuals were deemed ineligible (3.5% of written requests); 298 individuals withdrew their requests (1.9% of written requests); and 2144 individuals died before receiving MAID (13.3% of written requests). In 2022, 4.1% of those who died in Canada received MAID. Of the 1837 clinicians involved in providing an assisted death in 2022, 67.7% were family physicians.

Case continued

The journey continues with your patient and after completing the first topics of online learning, the resident confidently opens the discussion about MAID; meanwhile, you access the provincial or territorial forms. Your patient verbally expresses that she believes she is eligible and wants to have the 2 assessments as soon as possible. She hopes you are able to do one of the assessments and, as her most trusted health care provider, she hopes you will consider providing MAID if she is found eligible. You and the resident discuss this and recognize additional training may be needed to do this thoroughly and appropriately. You are able to connect with a colleague who has been doing MAID assessments for some time and they encourage you to consider doing the assessment, with some support and training in topics 3 (how to do a MAID assessment) and 5 (providing MAID) of the CMC. You note completion of these topics requires a component of both self-study and participation in facilitated sessions taught by CAMAP faculty members, and that both in-person and virtual offerings are available.

A qualitative research study was done on the knowledge and skills acquired by clinicians in the first 3 years after legalization of assisted dying in Canada.¹⁰ The study reported there was limited or no access to training and mentorship, as this field of health care was new. Early adopting providers used a variety of strategies including organizing education groups to compare approaches and strategies and reflect on unexpected experiences. Overall, there was a desire for early training programs and mentorship. Their experience emphasized the importance of accessible guidance opportunities. These research findings highlighted the need for a curriculum like the CMC. In addition, a comprehensive literature review of 9284 titles published from 2011 to 2021 revealed detailed information on 104 programs offering training for end-of-life discussions with adult patients and families.¹¹ While the long-term impact on practitioners and patients was not well identified, many programs highlighted the benefits of interdisciplinary learning and discussion. No comprehensive MAID communication training program was identified.

Case continued

While learning more about the components of a MAID assessment, you become increasingly aware of additional supports from which you would benefit. This includes knowing the local social work and nursing supports in your community, as well as a network of colleagues who also assess and provide MAID in your region and across Canada. While this particular patient is known to you, has the capacity to make medical decisions, and has a life-limiting condition that will lead to an advanced state of irreversible decline in capability, you realize not all patients are the same. In assessing other patients, you may recognize some limitations of capacity, uncertainty about prognosis, concurrent mental health disorders, social isolation, lack of access to services, and additional vulnerabilities. The curriculum provides additional education on the final 3 topics—topic 4, assessing capacity and vulnerability; topic 6, navigating complex cases with confidence; and topic 7, MAID and mental disorders. You learn about CAMAP and realize this community of practice may provide valuable assistance to you in delivering high-quality care in aspects of MAID as a clinician and leader and instructor to family practice residents.

Clinicians’ perspectives on high-quality care in MAID were explored in a 2021 qualitative study conducted at 4 Canadian centres.¹² Among themes that emerged were the need to support and sustain both clinicians and institutions through education and training, and to encourage interprofessional collaboration. In line with these themes, a group of clinicians founded CAMAP in 2016 to be an interdisciplinary professional and educational association of those who perform this work. The development of CAMAP allowed for confidential sharing of best practices and comparing approaches to complicated and complex scenarios. The organization established a confidential online forum for members and continues to support it so questions related to patient eligibility, practical clinical considerations, and logistic challenges can be addressed by a peer group. Small task forces develop guidance documents for the profession that are reviewed by a wider group of consultants and approved by the CAMAP board. In 2021, CAMAP was granted charitable status.

Case resolution

After completing topics 2 and 3 in the CMC, you assess your patient and find she meets the criteria for MAID. Through the CAMAP community of practice forum you find another assessor who is an experienced provider. Although you are not ready to provide MAID on your own, the patient asks you to be there and you attend the event about 4 months after she first brought up the topic. She and her family are reassured to see you there and express gratitude and appreciation for your assistance and support over the years, but particularly in these final stressful months. As you reflect on her completed life, alone and then with the family practice resident, you recognize this key role in providing compassionate care.

Final thoughts

The CMC represents a new chapter in Canadian health education. It is one of the first examples of a curriculum purposely built to address the needs of both nurse practitioners and physicians in providing MAID. It is one of the only educational programs that relied on input from key clinician organizations and was informed by people with lived experience who provided input at various stages during development.

Whether or not clinicians take all or some of this program, the development sequence will continue to inform clinicians in Canada about better approaches to educational training. The program itself should help ensure a resilient health care team ready to meet the demands of Canadians.

CAMAP offers members participation in an accredited and confidential community of providers, case-sharing webinars, symposia on topics of interest and concern, and organizes an annual conference on MAID. Clinicians interested in incorporating MAID to an existing practice or adding MAID to the range of work they provide will likely find the support of a professional organization to be essential.