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Slide1
Education Day: A Forum on Medical Assistance in Dying
Sept. 23, 2016Slide2
@MBCollegeRNs
#crnmED16Slide3
Welcome!
#crnmED16Slide4
Global Perspective: An Overview of International and Canadian Law
Dr. Mary Shariff BSc LLB LLM
PhDSlide5
Global perspective:
an
overview of international and Canadian law
Mary J Shariff PhD
Associate Professor
Associate Dean Research and Graduate Studies
Faculty of Law, University of Manitoba
September 2016
9/30/2016Slide6
DEFINITIONS
premised on
voluntariness
EUTHANASIA
: lethal injection
PHYSICIAN ASSISTED SUICIDE
prescription
for
self-ingestion
ASSISTED SUICIDE
Not necessarily a physician
Other methods
MEDICAL
ASSISTANCEIN DYING
9/30/2016Slide7
Sue
Rodriguez
case (1993 SCC)
FACTS:
ALS
(progressive, degenerative neuromuscular
disease.)
terminally ill
:
life expectancy
between 2 and 14 months
Prohibition on assisted suicide
is an Infringement on rights: equality, liberty and security.Criminal Code ProvisionSection 241. Counselling or aiding suicide Every one who(b) aids or abets a person to commit suicide,whether suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.Slide8
Sue
Rodriguez
case (1993 SCC)
SCC
MAJORITY DECISION
:
infringements
(right
to security and
equality)
justified and proportionate
in order to
protect life and those who are vulnerable in society.Note dissent by MacLachlin J- prohibition was arbitrary and any risks can be mitigated by a regulatory regime.SHARIFF_DRAFT ONLY – not for circulation9/30/2016Slide9
Post 1993 Legislative Developments:
“Physician Conflict”
NETHERLANDS – 2002
BELGIUM- 2002
LUXEMBOURG - 2009
“Death with Dignity”
OREGON – 1997 (1994)
WASHINGTON – 2009 (2008)
VERMONT -2013
CALIFORNIA -2016
COLORADO Nov 2016?
AUTONOMY
=
Free from State Interference in Personal Decision-Making
SHARIFF_DRAFT ONLY – not for circulation
9/30/2016Slide10
Post 1993 Developments
:
Netherlands, 2002
Focus on the Physician and a “Conflict
of
Duties”
Duty to protect life
versus
Duty to relieve suffering
Key Points
Court Cases prosecuting physicians
Euthanasia (or
PAS
)
offered as measure of “last resort
”
Framed as a
physician
defence
to charge of homicide
Consent is not the justification
for offering euthanasia option but is a
necessary pre-condition
to carry it out.
Establishes the importance of the
physician-patient relationship
Treatment
Suffering
NECESSITY DEFENCESlide11
Belgium
(2002)
L
uxembourg
(2009)
Legislation
SIMILAR:
framework as Dutch legislation
Euthanasia or PAS
DIFFERENT:
not conceptually based on physician conflict of dutiesnot required to be a “measure of last resort”decreased relevance of physician-patient
relationshipincreased focus on autonomy & self-determination
increased focus on subjective perspectives o “suffering”Slide12
Post
1993
Developments:
“
Benelux” Models
Euthanasia option (or PAS)
1. Adult
Conscious
Competent
Request
: voluntary, well-considered;
Suffering:
lasting, unbearable (physical or mental) Condition: medically futileIllness or Accident: serious, incurable Netherlands (2002)Belgium (2002)Luxembourg(2009)
Concept A: Autonomy
…
2. by Advance Directive
Unconscious
(
Neth
,
Belg
, Lux)
Conscious?
(Netherlands)
4. Minor children (12-15)
parental agreement
Netherlands
“capacity
for
discernment”
Belgium (2014)
*
Neonates:
Groningen Protocol
(Netherlands)
3. Minors
16+
Belgium (emancipated)
Netherlands
Concept B: Relief of Suffering
…
SHARIFF_DRAFT ONLY – not for circulation
9/30/2016Slide13
THE UNITED STATES
“Right to Die”
“Dying with Dignity”
removal of life support / feeding tubes
Terry
Schiavo
Collapsed and Cardiac Arrest, PVS
Removal of
Feeding tube
( 2005)
Privacy right analysis.
Nancy Cruzan
Car accident, PVSRemoval of Life Support ( 1990)Liberty right – evidence of wishesNegative Rights-based arguments: Right
to “privacy”Right to “liberty
”Slide14
THE UNITED STATES
Conceptually and Politically
extension of “
dying* with dignity
”
a
right to be free from
…
….Physician Assisted Death
Terminal illness
only*
Prescription for lethal dose meds
only** (prescription is a “lesser” involvement than WD life support)Slide15
Post
-1993
Developments: United States
Oregon (1994 –public vote, 1997)
Washington (2008 –public vote, 2009)
Vermont (2013)
California (2015)
Patient Qualifiers:
Capacity and Consent
Adult (18 years or older)
terminal illness (6 months or less)
prescription
for lethal medicationresidency requirements*Montana (2009) court case Baxter v Montana
Consent is the justification; physician defence i.e. autonomySlide16
United States: Physician Assisted only
BUT
US MODEL CRITICIZED
Best practices
–
lethal injection (more humane, controlled, more safe)
“6
months or less to
live”
–
impossible to
evaluate
Suffering can be equal or greater in patients with other conditions who are not terminally ill. lethal medications in non-controlled environments Slide17
Switzerland: Assisted Suicide only
CRIMINAL CODE
: ASSISTED SUICIDE IS ONLY ILLEGAL IF DONE FOR “SELFISH” REASONS*
Practice evolved through “right to die” organizations
assisted suicide only
physician
involvement:
best practice is to use particular lethal medication – requires
prescription
no residency requirement
9/30/2016Slide18
COLOMBIA – 1997 and 2015
1997 Court Case
euthanasia had lesser punishment than homicide
Argument: unconstitutional: right
to life
and equality for terminally or gravely ill persons
Criminal Code upheld
But
also unconstitutional
to
sanction medical doctor for practice of euthanasia
if
terminal illness informed consent2015 – issued guidelines Euthanasia; terminal illness or terminal phase; consent by AdvDir allowed“Interdisciplinary Committees” – panel evaluation9/30/2016Slide19
Key International Imports into the Canadian Debate
Between
Rodriguez
and
Carter
: Oregon
, the Netherlands, Washington, Belgium and
Luxembourg (Montana
and
Colombia cases)
Best practices
lethal injection (more humane, controlled, safer than lethal medications in non-controlled environments; address any complications)“6 months or less to live” – impossible to evaluate Suffering
can be equal or greater in patients with other conditions non terminal conditions (mental illness)Children and Teens suffer too
Autonomy and Controladvance directivesMental illness
9/30/2016Slide20
Carter v. Canada (2015 SCC)
2011
: Gloria Taylor
challenges prohibition on assisted suicide in B.C. court
diagnosed with ALS
fatal neurodegenerative disease
(ALS
)
Section 7 :
life, liberty and security
Gloria Taylor: Medical Condition: ALS
Other Plaintiffs
: Lee Carter and Hollis Johnson: took mother Kay Carter (suffering from spinal stenosis) to an assisted-suicide clinic in Switzerland to die. A physician willing to assistBC Civil Liberties
9/30/2016Slide21
Criminal Code Provisions
Section 241
.
Counselling
or aiding suicide
Every one who
(
b
)
aids or abets a person to commit suicide
,
whether suicide ensues or not, is guilty of an indictable offence and liable to imprisonment for a term not exceeding fourteen years.Section 14 Consent to death14. No person is entitled to consent to have death inflicted on him, and such consent does not affect the criminal responsibility of any person by whom death may be inflicted on the person by whom consent is given.Argument: Criminal code provisions are to protect the vulnerableProhibition on aiding suicide is arbitrary, overbroad and grossly disproportionate
9/30/2016Slide22
The Carter Case (SCC 2015)
Per Chief Justice
McLachlin
The
Cruel Choice:
“can take her own life prematurely, often by violent or dangerous means, or she can suffer until she dies from natural causes.
”
Because of
life, liberty and security rights
, the absolute prohibition is
overbroad
Evidence
from other jurisdictions demonstrate can use safeguards to Protect the Vulnerable Canadians and ensure medical condition, voluntariness and consent 9/30/2016Slide23
The Carter Case (SCC 2015)
The Declaration of Invalidity (para 127)
…s
. 241 (b) and s. 14 of the Criminal Code
void insofar
as they prohibit physician-assisted death
for
:
a
competent adult person
who
(1) clearly consents to the termination of life; and (2) has a grievous and irremediable medical condition (including an illness, disease or disability) that causes enduring suffering that is intolerable to the individual in the circumstances of his or her condition. Two key points:creates analytical space for the Benelux ModelCourt gave Parliament 12 months plus another 4 months to create legislative response 9/30/2016Slide24
QUEBEC: BILL 52
“An Act Respecting End of Life Care”
only for insured persons under
Health Ins Act
Patient Qualifiers
“full age”
capable of consent
Voluntary and informed request
Serious and incurable illness
Advanced state of irreversible decline in capability
=
terminal ill/end of life.
Constant, unbearable suffering (physical or psychological)9/30/2016Slide25
QUEBEC: “An Act Respecting End of Life Care”
Came into effect
December 2015,
Some issues/criticisms:
1. Health
(Provincial) vs
Criminal
(Federal)
2. Euthanasia
only
3
. “narrower than
Carter”: possibility of challenge“health-based rationale” not a rights-based rationale“Terminal illness” 4. was Risk of Prosecution between Dec 2015- Feb 20169/30/2016Slide26
Carter: Substance of the Patient Right?
Nature of the Argument:
Criminal
Code
prohibition on
assisted suicide
241(b)
Section
7 rights
:
liberty
, security and lifeinfringes
“Cracks open” the Criminal Code
to remove prohibition for physicians
to provide MAID in specific circumstances
“Right” to Die
9/30/2016Slide27
Act to Amend Criminal Code:
Medical
Assistance in Dying (SC 2016 c.3)
Key Aspects
Criminal law immunity
from
: homicide; administering noxious thing; and aiding suicide
Criminal law immunity
to
: medical practitioners and nurse
practitioners to provide medical assistance in dying
and
to pharmacists and other persons who assist in the process;SO Regulation is required***Health Care aspects?:room for regulation under health care:provincial and licensing bodies/colleges9/30/2016Slide28
Act to Amend Criminal Code:
Medical
Assistance in
Dying (
SC 2016
c.3
)
MAID:
Administering
or
providing
substance that causes death
Patient Qualifiers:at least 18 years of age capable grievous and irremediable medical condition;voluntary request informed consent (after having been informed of the means that are available to relieve their suffering, including palliative care)9/30/2016Slide29
“grievous and irremediable”
(
a)
serious
and incurable illness, disease or disability
;
(b)
advanced
state of irreversible decline in capability
;
(c)
causes
enduring physical or psychological suffering intolerable to them and that cannot be relieved under conditions that they consider acceptable; and(d) natural death has become reasonably foreseeable, taking into account all of their medical circumstances, without a prognosis necessarily having been made as to the specific length of time that they have remaining.9/30/2016Slide30
safeguards
Written requests
Waiting period (10 days, less if imminent)
…
9/30/2016Slide31
other key considerations
Conscience protection?
“
nothing in this section compels
an individual to
provide or assist in providing
medical assistance in dying
.”
Palliative Care?
Independent Reviews
:
Mature Minors
Advance Directives Mental illness9/30/2016Slide32
future challenges?
Mature minors
Advance directives
Mental illness
SHARIFF_DRAFT ONLY – not for circulation
9/30/2016
Current challenges?
Julia Lamb
case (BC)
Challenging “reasonably foreseeable” criteria
spinal
muscular atrophy (SMA)
progressive
destruction of ability to speak, walk, swallow and breathe.Slide33
future challenges?
Conscience protection
Providing or Participating is
entirely
voluntary
in:
All legislated jurisdictions:
Oregon, Washington, Vermont, California, the Netherlands, Belgium and Luxembourg
No duty for a physician to provide or participate
No duty to refer to a willing physician
Duty to transfer medical record upon request
Duty to inform of refusal promptly
*duty to arrange to provide information ?Slide34
South Africa – April 2015
Ford v Minister of Justice (High Court of South Africa)
Constitutional argument (cites Carter case)
Homicide provisions unjustifiably
limit constitutional rights to
human dignity
and
freedom of bodily and psychological integrity
PAS
or Euthanasia
competent
adult acting freely and voluntarily,
terminally ill, suffering intractably severely, curtailed life expectancy of weeks only9/30/2016Slide35
Questions?
#crnmED16Slide36
Coffee Break
See you back at 10:30 a.m.
#crnmED16Slide37
The Public Voice: Consultations and
Working with the
Legislative Committee
Dr. Harvey Chochinov MD PhD FRCPC
FRSCSlide38
Medical Assistance In Dying (MAID) in Canada
Harvey Max Chochinov OC MD PhD FRSC
Canada Research Chair in Palliative Care
Former Chair, External Panel on Legislative Options to Carter v Canada
Director, Manitoba Palliative Care Research Unit
Distinguished Professor, Department of Psychiatry
University of Manitoba, CancerCare ManitobaSlide39Slide40
Stability of Will to Live with Pain in an 80 Year-old
Patient with Colorectal Cancer
--
Will to Live
Lancet. 1999;354:816-9. Slide41
Stability of Will to Live with Pain in an 80 Year-old
Patient with Colorectal Cancer
---- Pain
Lancet. 1999;354:816-9. Slide42
Chochinov et al. Social Science and Medicine 2002Slide43Slide44Slide45Slide46Slide47
Supreme Court declared sections 14 and 241(b) of the Criminal Code invalid insofar as they prevent physician-assisted death for a competent adult person who (
1) clearly consents to the termination of life; and (2) has a grievous medical condition (including an illness, disease, or disability) that is irremediable (cannot be alleviated by means acceptable to the individual) and causes enduring suffering that is intolerable to the individual in the circumstances of his or her conditionSlide48Slide49Slide50Slide51Slide52Slide53Slide54Slide55Slide56Slide57Slide58Slide59Slide60
Who
is eligible for
MAID?
- be
eligible for health services funded by the federal government, or a
province
or territory
- be
at least 18 years old and mentally competent
- have
a grievous and irremediable medical condition - not the result of outside pressure or influence - give informed consent to receive medical assistance in dying i.e. be told about: your medical diagnosis;
available forms of treatment available options to relieve
suffering, including palliative careSlide61
Grievous and irremediable medical condition
have a serious illness, disease or disability
be in an advanced state of decline that cannot be reversed
be suffering unbearably from your illness, disease, disability or state of decline; and,
be at a point where your natural death has become reasonably foreseeable, which takes into account all of your medical circumstancesSlide62Slide63Slide64Slide65Slide66
Questions?
#crnmED16Slide67
Lunch
See you back at 12:45 p.m.
#crnmED16Slide68
Inter-professional Teamwork: A Discussion with the Provincial
Services Team
Medical Assistance in Dying (
MAiD
)
Provincial
Services
TeamSlide69
Medical Assistance in Dying (MAID)
Provincial MAID Clinical Team
CRNM Educational Day
September 23, 2016Slide70
WHAT, WHO, WHERE, HOW, WHEN, WHYSlide71
WHAT
AS = assisted suicide
Physician prescribes medication
Oral medication
Patient (self) administers medication
Time & Place of their choosing
AE = assisted (voluntary) euthanasia
Physician prescribes medication
IV medication
Physician administers medication
Booked ‘procedure’Slide72
WHO
SCC = physicians ONLY
Federal legislation = physicians + nurse practitioners
‘Reasonable knowledge + skill in accordance with provincial laws/rules/standards’
Other HCPs covered to participate in process
MB = CPSM registered physicians
‘Appropriate knowledge + technical competency’
Will be credentialed privilege in RHAs
CRNM draft standard for NPs
Death certificate issueSlide73
WHERE
Hospital
Faith based facilities
Home
Suitability of space
Other
Public place
Dedicated place
Other considerations
Family / Friends
Not required
What will they see?
Spiritual care / Other supportSlide74
HOW (MAID Team)
3 MDs + 2 RNs + 2 SWs + 2 pharmacists + 1 SLP
Brought together by province (health + justice) + various colleges
Provincial service situated in WRHA
Unique to MB
Very much a team approach
Unanimous vs
Consensus
Conscientious participation (vs objection)
Debrief regularly
Laugh lots + Cry often
Team set up to provide all parts of MAID but welcome participation from othersSlide75
HOW (Eligibility + Capacity + Consent)
2 independent MD/NP assessments re: eligibility
Competent adult (18 years) + eligible for health services
Grievous + Irremediable medical condition
Serious / Incurable / Advanced / Suffering / No
tx
/ Death foreseeable
Voluntary request
(time alone)
Informed consent after review all options including
palliative care
Written witnessed request
10 clear days b/w written request + procedure(Re)confirm consent at time of procedure1 MD must do ALL parts (“administering physician”)Slide76
HOW (In practice)
Initial request (email / voicemail / other HCP)
Triage
Chart review (+/- consult specialist)
+/- SLP assessment
Assessments
MD + RN
+ SW (+/- SLP)
Approximately 2 hours
Explore: why / why now / suffering / unmet needs / alternatives
Review procedure + obtain consent
Time alone with patientRemind can rescind request ANYTIMESlide77
HOW (Medications – Principlesto Consider)
Administration
Patient
Physician
Route
Oral
IV
Pharmacodynamics
Quick
Painless
Lethal
Other considerations
Minimal side effectsMinimal (no) complicationsMinimal (no) risk failureAlternatives in case of allergyMB only IV protocol supportedStandardized prescriptionSlide78
WHEN
Legislation requires
10 clear days
from written request to procedure
Can shorten time if both MD/NPs agree
imminent
risk
Death
Loss capacity to provide consent
Legislation requires
immediately before
procedure patient:
Has opportunity to withdraw their requestGives express consent Implies need to have capacitySlide79
WHY (Common Themes)
“I am done”
Desire for control
Loss of identity
Fear of the endSlide80
MB MAID Stats as of Sept 19/16
51 contacts
12 received MAID
12 active cases
11 declined by MAID team
14 died without MAID
2 unable to contactSlide81
NURSING PERSPECTIVESlide82
HOW (did I get here)
Joined “working group” in February 2016
Cautiously in favor of assisted death in certain circumstances
WRHA + CRNM sanctioned RN participation from the get-go
Became “clinical team” at our first meeting
Evolved to full
time nursing
position- Client Care Coordinator
due
to
patient volume, requests for education Slide83
Nursing role
Information resource for other nurses, health care providers and the public
Participate in development of policy, procedure, guidelines, education etc.
Triage referrals received from patient or health care provider
www.wrha.mb.ca/maid
Participate in patient
assessments
Participate in determining
patient eligibility with team
Communication/coordination with patients and HCP’s
Procedure:
Establishing IV’s
Preparation of medication Nurses may prepare but can NOT administer under any circumstance Support for patient, family, team members Pre and debriefing with HCP’s pre and post procedureSlide84
Phone Triage (30-60 minutes)
Initial
contact with
patient
Most are very forthcoming and have been considering
MAID
for some time
History + reason
for requesting MAID
Symptoms/suffering Treatments tried/considered
Family involvement
Provide information regarding criteria and process
Obtain permission to review medical recordsAnswer any questionsDo their care providers know? Encouraged to include primary care providers, but respect their privacy if notSlide85
Patient Assessments
Team
discussion AFTER
2 independent assessments
We meet
weekly + talk
daily
All input valuable
Do they meet criteria?
Do they need further workup/consults?Psychiatry, specialist, imaging, labs etc.
Anything we can provide or suggest?
Is venous access sufficient?
PICC needed ? Concerns? Unanimous support of all members necessary Slide86
What we have learned
Not uncommon for people with life limiting illness to express a wish to die
In response to temporary distress?
Expression of suffering?
Information seeking?
Is the request persistent?
Specific request for MAID?
Conversations about death and dying take time
Validate they were heard
Acknowledge the importance of a discussion
Make time yourself or refer to someone who can Slide87
Practice Tips
Consider
your beliefs about medical assistance in dying early
What
aspects are
you comfortable with? What are you not
?
Conversation, assessment, procedure
Any anticipated or current objection should be communicated to
supervisors
ALWAYS
ensure patient does not feel abandoned or isolatedIdentify resources available to best provide support to the patient if you feel you cannot or are unsure howSlide88
Practice Tips II
Acknowledge comments
about MAID
Be nonjudgmental + respectful of diverse views
Take the opportunity to
identify unmet needs
!
Be mindful of the difference in exploring a patient request and expressing your own
opinion
D
espite
optimal end of life care, patients will still want MAIDSlide89
Practice Tips III
To be
present at procedure you
MUST
be in agreement that patient meets criteria
Read and familiarize yourself with bill
C-14 + CRNM documents +/- CPSM
Review physician
assessments + patient chart + have
discussion with
MD/team
Especially if you have not been present for patient assessment
Document that you have done this!When in doubt, seek guidance from CRNM, CNPS and/or MAID Clinical TeamDocument ALL interactions with patients about MAIDLegal and professional obligationCommunication with other team membersSlide90
Therapeutic Relationships
Early on our team identified need to create relationships and “get to know” the patients
For our own well being
To acknowledge and share in the patient’s humanity
Very
personal and private process for patient and
family
Unfamiliar
faces at time of procedure can cause unnecessary discomfort for not only the patient and family but for the providers as
well
A lot of sadness in their stories but they share a lot of joy and laughter as well
Encourages trust, support and honestySlide91
EXPLORING AN INITIAL ENQUIRYSlide92
EFFECTIVE COMMUNICATION
‘Being curious and respectful human beings in relationships shaped by mutuality + reciprocity
’Slide93
ENGAGING / CONNECTING
Listening
Acknowledgement
Trust
PresenceSlide94
EXPLORING SUFFERING
Fears
SadnessAnger
Regrets
Meaning + Purpose
‘Sit Down &
Lean In’
Dr. Mike
Harlos
www.virtualhospice.caSlide95
RECOGNIZING AMBIVALENCE
Some is normal
May fluctuateSlide96
WHAT DO YOU SAY:COMMON THEMES
Open vs Closed
“MAID neutral”
Do not abandonSlide97
IMPORTANCE OF SELF CARE +TEAM
Obstacles to self care: ‘Ethical Responsibility’
Sanctioned regular pre-brief + de-brief
What makes teams workSlide98
“FEEL DEEPLY,
ACT WISELY”Slide99
Questions?
#crnmED16Slide100
Coffee Break
See you back at 3 p.m.
#crnmED16Slide101
Conscientious Objection and Other Ethical Questions
Darlene O’Reilly RN BN
MHS
Ryan
Shymko RPN BA
MA
Tracy Olson
LPNSlide102
Medical Assistance
in Dying
Medical Assistance in Dying- CRNM Education Day
September 23, 2016Slide103
Objectives and Outline
What is Conscientious Objection?
What are Values?
Informed Choice
Duty to Provide Care & Case Example
Counseling in Medical Assistance in Dying
Case Studies
Nursing Responsibilities
Do’s and Don’ts
ResourcesSlide104
Conscientious Objection
What is Conscientious Objection?
In the nursing context, refers to a nurse’s refusal to provide a service that is within their competence
It encompasses moral beliefs about what is right and wrong
How do we address and prioritize our values?Slide105
What are Values?
Fundamental beliefs that we consider important to us
Well-established by early adulthood, but can change over time as we gain new experiences that question our values
Family background, culture and religion can play an important role in our value systemSlide106
Professional Values
Value systems that our professions strive to uphold and are outlined in each profession’s Code of Ethics:
Client Centered
C
are
CRNM: “Promoting and respecting informed decision making”
CLPNM: “Informed decision making”
CRPNM: ”Respects people’s autonomy and their right to choose by recognizing them as full partners in decision-making”Slide107
Informed Choice
As a nurse, you make an informed choice as to whether you will participate in Medical
A
ssistance in Dying
This is balanced between the duty to provide care vs. the right to morally object to provide a service
These objections may occur frequently or rarely depending on your role and your practice area
The onus is on you, as the nurse, to reflect and determine what this means to you and whether you will participateSlide108
Duty to Provide Care
As nurses, each of our COE provide guidance about our duty to provide care
Balance between moral objection vs. fear or lack of understanding
Fear or misinformation about Medical Assistance in Dying does not absolve a nurse of their duties and ability to provide care
If a nurse chooses not to participate due to a moral objection, they still must ensure continuity of care through referralSlide109
Case Example
Tina is a nurse who works on a palliative care unit where a client she works with has requested Medical Assistance in Dying. The Implementation
T
eam has been working with the client to provide the request
Tina objects to Medical Assistance in Dying and has avoided participation, including any discussion(s) with the client and family
On the day of the procedure, Tina calls in sick for her shift due to moral distress related to the procedureSlide110
Questions:
What moral and ethical principles are involved here?
Should Tina have called in sick for her shift?
What role(s), if any, does the employer have if a nurse has a conscientious objection?
What could Tina have done differently to address her moral objection?Slide111
Counseling in the Context of Medical Assistance in Dying
Counseling in Medical Assistance in Dying has a different meaning than the traditional form we use in practice
In Medical Assistance in Dying, counsel refers to the concepts of “procure, solicit and incite”
This does not prevent nurses from having conversations with the client to address underlying needs or discuss pain and sufferingSlide112
Case Study #1
A client you are working with has a long standing history of mental health issues, including a diagnosis of Major Depressive Disorder. On your shift that day, the client informs you that they are experiencing suicidal ideations (thoughts of self-harm) and they want to kill themselves. The client asks you whether they can access Medical Assistance in Dying because the emotional pain they are enduring is intolerable. Slide113
Questions:
What
ethical principles would guide the nurse’s decision-making in this case?
Is it the nurse’s responsibility to determine eligibility for Medical Assistance in Dying?
How might the nurse attempt to address the client’s pain and suffering?Slide114
Case Study #2
A nurse is visiting a female long-term home care client with a diagnosis of Multiple Sclerosis (MS). The client has been physically deteriorating for the last year and has told the nurse on many visits that she finds the pain to be intolerable. Palliative Care has been consulted for placement, but the client has chosen to live at home
During this visit, however, the client informs the nurse that she has requested Medical Assistance in Dying and has met with the Implementation Team
The nurse has identified that he/she has a conscientious objection and does not want to participate in the client’s careSlide115
Questions:
What ethical principles
are involved here?
Can the nurse refuse to provide care to the client based on a conscientious objection?
W
hat responsibilities does the nurse have?
Does the nurse have a responsibility to inform their employer of the conscientious objection?Slide116
Nursing Responsibilities
All
nurses must:
Familiarize
themselves with the wording of the new Criminal Code
provisions
Review
any guiding documents from their regulatory
college(s)
Understand
the applicable policies, guidelines, procedures and or processes in place to guide medical assistance in dying in their practice
setting
Ensure that their practice is in accordance with the applicable provisions of all other applicable laws, rules, and standards
Seek legal advice (when applicable) to understand the relevant provisions of the Criminal Code; for example: CNPSSlide117
Do’s and Don’ts
Do:
Acknowledge the client’s request in a caring and compassionate
manner
Explore the client’s suffering
Collaborate with colleagues and your employer to meet client needs
Consider best practice guidelines
Consult your regulatory college if you have questions about Medical Assistance in Dying
Explore your own feelings about how you will participate in Medical Assistance in Dying
Make referrals as appropriateSlide118
Do’s and Don’ts
Don’t:
Ignore a request
or request for information
on Medical Assistance in Dying
Counsel on Medical Assistance in Dying
Minimize the client’s request or feelings
Provide information on Medical Assistance in Dying unless the client explicitly asks
Guess or speculate- make sure the information is correct!Slide119
Thank you!
Questions?Slide120
Resources
Canadian Nurses
Protective
Society:
http://
www.cnps.ca/index.php
Government of Canada Department of Justice Medical Assistance in Dying Q
&
As:
http://
www.justice.gc.ca/eng/cj-jp/ad-am/faq.html
WRHA Medical Assistance in Dying: http://www.wrha.mb.ca/maid/
CNA Code of Ethics: https://www.crnm.mb.ca/support/resources
CLPNM Code of Ethics: http
://www.clpnm.ca/standards-guidelines/code-of-ethics
/
CRPNM Code of Ethics:
http://www.crpnm.mb.ca/psychiatric-nursing/standards-and-code-of-ethics
/
Slide121
Contact Us!
Ryan Shymko; RPN, BA,
MA
Practice Consultant/Deputy Registrar
CRPNM
204-888-4841
E-Mail: rshymko@crpnm.mb.ca
Darlene O’Reilly;
RN, BN,
MHS
Practice Consultant
CRNM
204-784-6465E-Mail: doreilly@crnm.mb.ca
Tracy Olson; LPN
Consultant, Professional Nursing PracticeCLPNM204-663-1212
E-Mail: tolson@clpnm.caSlide122
Questions?
#crnmED16Slide123
Conclusion
#crnmED16Slide124
See you at our 2017 education day!