A qualitative study of experiences of institutional objection to medical assistance in dying in Canada: ongoing challenges and catalysts for change | BMC Medical Ethics

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Sample description

Seventy interviews were conducted for the broader project on MAiD decision-making: 31 with family caregivers; one with a patient; 32 with MAiD assessors/providers (25 physicians and 7 nurse practitioners); and 11 with members of MAiD teams at health authorities and institutions. Five participants had overlapping roles: four MAiD team members were also MAiD assessors/providers, and one MAiD assessor/provider was also a family caregiver. Two interviews with family caregivers involved two participants, at the interviewees’ request (e.g. a child of a deceased parent and their spouse).

In 48 of the 70 interviews, participants discussed institutional objection: 40 interviews described direct experiences, while 8 interviews solely involved participants’ perceptions of institutional objection more generally. The proportion of participants discussing institutional objection by participant role is set out in Table 1.

Table 1 Interviews in which participants discussed institutional objection

This subset of 48 interviews discussing institutional objection, which was analyzed for this study, ranged from 50 to 203 min (median of 94 min). Table 2 sets out participant demographics. Table 3 sets out characteristics of the 6 patients who family caregivers described experienced an institutional objection (characteristics of patients reported on by family caregivers from the broader study are also included to facilitate comparison).

Table 2 Characteristics of participants (total sample and institutional objection sample)
Table 3 Characteristics of patients discussed by family caregivers (total sample and patients who experienced an institutional objection)

Participants reported institutional objections from a range of faith-based and non-faith-based institutions including hospitals, palliative care units, hospices, and long-term care facilities. While institutional objection occurred in all provinces, MAiD assessors/providers and MAiD team members from Ontario commented on more ongoing challenges with institutional objection than those in British Columbia and Nova Scotia.

We identified six overarching themes: (1) basis of institutional objection; (2) scope of objection; (3) transparency of position; (4) impacts on patients; (5) impacts on health practitioners; and (6) catalysts for institutional change. Additional illustrative quotes for each theme are provided in Table 4.

Table 4 Additional illustrative quotes regarding institutional objection by theme

Theme 1. basis for institutional objection

There were two primary bases for institutional objections. First, objections based on religious values, which commonly arose in faith-based institutions (including hospitals, hospices, long-term care facilities, and home care providers). A physician noted:

“Catholic hospitals and some of the Jewish hospitals will not allow it and some of the hospices that have religious affiliations won’t allow it. So, you don’t get to see patients in them.” (MAiD assessor/provider 4)

The second basis for institutional objection was a particular philosophy of palliative care which arose in both faith-based and non-faith based palliative care settings (including hospices, and palliative care units within hospitals). For example:

“In the beginning there were a lot of palliative care facilities that also just said, ‘well we won’t do that work.’ Non-faith based, just philosophically, ideologically.” (MAiD assessor/provider 8)

“There’s a large amount of overlap because many palliative care institutions are faith-based, especially hospices, because palliative care is sort of a ‘churchy’ speciality. I think palliative care has a role to play in that lack of access, in those difficulties of access as well.” (MAiD assessor/provider 15)

Participants also reported that how an institution’s values shaped its position on MAiD was often determined by a key internal stakeholder, for example, the medical director of a palliative care unit, or chair of the board of directors. Staff in an institution were described as often being supportive of MAiD, despite the top-down decision. For example, a family caregiver commented:

“…even though the majority of the people who worked at [institution] were intensely religious, either intensely Catholic or intensely Jewish … everybody supported [the patient’s] choice … It was specifically the board, and the chairman of the board, with them saying ‘No, we are too Jewish for that. We will not allow it’.” (Family caregiver 28)

Similarly, a nurse practitioner noted:

“…the people in the high positions, somebody has an opinion and becomes vocal and shuts it down for the entire facility.” (MAiD assessor/provider 26)

Some participants provided examples in which the board’s position seemed driven by a desire to maintain the faith-based ethos of the facility, not because the board members necessarily agreed with this position, but rather to appease stakeholders, such as charitable donors, outside of the organization. For example:

“Hospices in Ontario are funded mostly by charitable donations. … the board of [hospice name] would need to make a decision that we are … forgoing that gift and willing to pay for another piece of property in order to have the option of doing this.” (MAiD assessor/provider 26)

Several participants highlighted that institutional objections in faith-based and palliative care hospitals, hospices, and aged care facilities were not universal. A physician noted:

“For me institutionally, I haven’t had any issues. Our palliative care unit is very supportive of MAiD … the downtown one the same thing. … There’s no beef between palliative care and MAiD. Which when I first discovered that was a thing, it kind of blew my mind.” (MAiD assessor/provider 20)

Theme 2. scope of objection

Participants described a range of aspects of MAiD that institutions objected to. Some institutions would not provide any aspect of MAiD or allow it to occur onsite. For example:

“…there is a care home downtown that I know I can’t go in and do an assessment there, I can’t go in and do a provision there, those patients need to come off the grounds of that building if I’m going to do assessments. I’ve done one in a café, I’ve done one in the park, done one on a park bench.” (MAiD assessor/provider 8)

Other aspects that institutions objected to included: providing information; allowing request forms to be signed and/or witnessed onsite; transferring patient records to a MAiD assessor or provider; inserting the IV for MAiD provision; and enabling specialist consultations (e.g. a psychiatry consultation).

In contrast to institutions with blanket refusals, other institutions took less restrictive positions to MAiD. Some prohibited MAiD provision but allowed eligibility assessments. Participants also discussed hospices that would permit MAiD but would not allow patients to be admitted for this purpose. For example, a physician observed:

“…they don’t admit people just for MAiD. So, if you were at home and wanted MAiD, they wouldn’t bring you in to get that, but they do have people who are there who request MAiD and have procedures there…” (MAiD assessor/provider 11).

However, even in institutions with less restrictive positions, MAiD access could still be a problem. Some objecting institutions that allow MAiD assessments still refused to provide information about MAiD or tell patients it was an option. Participants reported this was related to the institutional position on MAiD, and in some cases also reflected individual conscientious objection of health professionals within the institution. For example:

“I don’t think patients of [Catholic hospital] know that’s an option for them, because nobody’s telling them…there is an active access issue because providers in that institution are not telling people that it’s an option.” (MAiD assessor/provider 11)

“I’m a little surprised that the palliative care team that came to visit us didn’t tell us about MAiD. … That team very much didn’t bring up MAiD or that that was an option, and very much sort of proceeded in this, you’re-going-to-die-naturally-at-home way, was the sense that we got. So that was, in retrospect, a little surprising to me because that was definitely not what he wanted or intended.” (Family caregiver 16)

Another barrier to access that participants attributed to institutional objection was the creation of additional logistics that slowed down or blocked a patient’s ability to access MAiD. A family caregiver described a long-term care facility that sought to have the patient use the institution’s form instead of the government one:

“… that was one of these other brick walls they tried to throw up, is ‘No, we won’t accept her form. You have to use our form and our lawyers have to sign it,’ and we’re like “No, they don’t.” So they just kept coming up with nonsense to try and dissuade her…” (Family caregiver 24b).

Many objecting institutions, particularly palliative care facilities, shifted from not allowing any aspect of MAiD to permitting assessments within a few years of MAiD becoming legal (discussed further in Theme 6). This change was attributed to several factors including institutions observing the impacts of forced transfers on patients, negative media attention, and the institution appreciating that an assessment is a conversation and believing “that it’s only actually killing someone that’s not okay” (MAiD assessor/provider 6).

Some participants highlighted that changes in institutional positions with respect to the scope of objections did not occur in a linear fashion, making them harder to navigate. For example:

“… our hospital/hospice/nursing care home vacillated on what they allowed. First, they allowed nothing. Then they allowed a request form. Then they allowed assessments but only if we did it undercover. Then they wouldn’t allow forms. Then they would allow them again.” (MAiD assessor/provider 24)

There was considerable institutional discretion in how MAiD requests were handled, and some participants emphasised that decisions about scope were often made on an ad hoc basis, resulting in the scope of objections between and within some institutions seeming inconsistent and arbitrary (Table 4).

Theme 3. lack of transparency regarding institutional position

Participants described varying degrees of transparency about institutional positions. On one end of the spectrum were institutions with explicit policies against MAiD, which were clearly communicated to patients, health professionals, and care coordination teams, and were publicly available. For example:

“They said, ‘We will not provide MAiD.’ It’s on their application to the hospice, the patients have to sign that they will not even discuss MAiD when they are admitted to a hospice.” (MAiD assessor/provider 26)

In contrast, a family caregiver indicated that many institutions’ positions are not publicly promoted: “I don’t think anyone on their website says we do or do not provide assisted dying…” (Family caregiver 6).

A few participants emphasised that there was a lack of transparency about the extent to which institutions would facilitate, or require, MAiD transfers. A physician noted:

“…if you ask some of the Catholic hospitals they will say, no, that they’re very compassionate and arrange these things [transfers for the purpose of MAiD]. My personal experience is that that’s not the case at all and that’s just nice talk. I mean I’ve recently had a couple of patients that have been in Catholic hospitals and there was no way we could get them moved to another hospital that allowed MAiD.” (MAiD assessor/provider 4)

Similarly, a family caregiver described how it was only just prior to the planned MAiD provision, despite that patient having been approved for MAiD months earlier, when, we found out that [the long-term care facility] would not allow her to have the procedure, her provision in her home” (Family caregiver 28).

Theme 4. impacts on patients

Institutional objections had several negative impacts on patients, across three broad domains: pain and other types of suffering relating to forced transfers; constrained choice regarding the patient’s end-of-life experience; and access being obstructed altogether.

Pain and other suffering related to forced transfers

The first major impact of institutional objection was pain and other suffering related to forced transfers out of objecting institutions. To sign forms and for MAiD assessments, patients were transferred to a variety of locations including other health care institutions, cafes, and public parks. For MAiD provision, patients were transferred home, to other institutions including hospitals and clinics, or to other locations such as funeral homes.

Forced transfers, when they occurred, had several consequences for patients. A physician described considerable pain experienced by a patient who was transferred out of a hospice for MAiD:

“He had dozens of bone metastases from prostate cancer. I can’t imagine the agony of a bumpy ambulance ride for his death. It was just – [long pause] you know, we make oaths to do no harm, and I certainly felt that was a harm to this man.” (MAiD assessor/provider 26)

Participants also described the emotional consequences forced transfers had on patients, including feeling stigmatised. A physician described a patient’s experience of stigma as being worse than the pain of the transfer:

“… the ambulance ride was going to be painful for him. But he said … ‘Honestly, the hardest thing about this whole thing is this, having to come to a different hospital like I’m doing something wrong.’ So, it was like even in the absence of pain, in the absence of everything, just feeling like I’m doing something wrong.” (MAiD assessor/provider 10)

Another emotional impact was imposing additional logistical roadblocks (which participants perceived were due to the institution’s objection to MAiD) which negatively impacted the patient’s MAiD experience:

Family caregiver 1: “There’s enough pain as it is. To then throw up these roadblocks on top of it is just cold….”

Family caregiver 2: “…that’s harm that can’t ever be undone.” (Family caregivers 24a and 24b)

Constrained choice and other impacts on the person’s end-of-life experience

A second major impact of institutional objection on patients was constrained choice and other negative impacts on the patient’s end-of-life experience. For example, some patients were forced to choose between MAiD and being admitted to hospice. A nurse practitioner noted:

“…in this [regional] community…it’s a huge barrier. We can’t go into hospice. In fact, hospice tells patients when they’re interviewing them that if they are considering MAiD they will not be allowed to come into hospice. … some families cannot cope with palliative care at home.” (MAiD assessor/provider 23)

Another example of constrained choice was that some patients were compelled to access MAiD in less-than-ideal locations. Participants described developing suboptimal solutions when a person did not have a residence to be transferred to, including transfers to an abortion clinic, HIV hospital, a boardroom, and a basement. A physician described struggling to find a place in a rural area for a patient who did not want to have MAiD at home for the sake of his young children:

“I am worried about the one gentleman … I’m not sure where he’ll go. I heard that provincial parks will allow MAiD. So I was going to contact … [name of provincial park] and see if we could go there, but it seems bizarre. I’d be willing to bring him to my backyard, you know. It’s strange not having any place to offer these people when they could legally probably die in the Tim Hortons [coffee and donut shop] parking lot, you know, or the middle of the street, but not in a hospital or a hospice. It makes no sense to me. I find it immoral.” (MAiD assessor/provider 26)

Obstructed access

A third impact on patients was that access to MAiD was at times precluded, for a variety of reasons. For some, it was simply too hard to pursue MAiD in the context of the institution’s objection. A physician commented: the persistence required to even get an assessment or have a conversation … about MAiD in a Catholic institution … is enormous (MAiD assessor/provider 15).

In other cases, patients were too sick to be transferred, some experienced a medical complication and died during the transfer, and some lost capacity due to medication needed to make the patient comfortable during the transfer. For other patients, MAiD access was compromised because they did not want to leave the facility where they had been living and where they knew the staff. A physician commented:

“I have had a number of patients that I assessed and were approved for MAiD in the hospital, but they said I’ve been living in this palliative care ward now for weeks and in some cases months, these are my family, I don’t want to leave them. I don’t want to go where there are strangers, where people don’t know me …” (MAiD assessor/provider 5).

Mitigating factors

Participants described several factors which mitigated these negative impacts on patients, including patient assertiveness. For example, she was bound and determined this was what she wanted (Family caregiver 24b). Also significant were family caregivers who advocated for the patient and were willing and able to facilitate the patient’s choice. For example:

“… they [the long-term care facility] actually told us she wasn’t allowed to access assisted dying there. And we said ‘That’s absolutely wrong. This is her home. She is legally – you are legally obliged to allow her to access it there.’ So again we had to fight that fight.” (Family caregiver 24a)

“…when that time came when we were scrambling to get a bed, because there’s not very many spaces available, we were told by a friend who had connections with hospice who said ‘If your intention is to have MAiD, don’t mention that in your hospice intake.’ … in general we were told, ‘Just keep that quiet just in case you come across somebody who’s not supportive. You can’t say that your intention is to enter hospice to have MAiD.’ So we didn’t say anything. Once we got there, then the conversations were okay…”

(Family caregiver 6).

MAiD assessors/providers and MAiD team members also played an important role in mitigating harm, using their knowledge of where to steer patients who are considering MAiD. For example:

“I always make sure to say, ‘But if you even think you might at some point in the future want an assisted death, do not go here and do not go there. Go here.’” (MAiD assessor/provider 15).

MAiD assessors/providers also described advocating considerably for patients, contacting hospital administrators and the media in egregious cases. Family caregivers spoke about the incredible personal dedication of clinicians, describing one physician as someone …who would move mountains to serve somebody however and wherever they need to be (Family caregiver 28). Some participants discussed assessors and witnesses who entered facilities posing as a visitor or family member for the purpose of signing forms or doing an assessment (though others expressed discomfort with this practice). For example:

“…we used all sorts of other tactics to get around it but, at the end of the day, they insist that patients obviously leave the facility to have MAiD.’” (MAiD assessor/provider 27)

Another mitigating factor was pre-existing care pathways set up to navigate the objection. One example was a partnership between a long-term care facility that refused to provide MAiD and a MAiD coordination team at a hospital cluster to facilitate the MAiD process: “…you had someone who you could discuss [MAiD] with, without having to involve the long-term care home (Family caregiver 12). Another example mentioned by several participants was a faith-based hospital with a dedicated separate area attached to it where MAiD provision was permitted.

Theme 5. impacts on health practitioners

Participants highlighted three main impacts on health professionals caused by institutional objections: emotional impacts; impacts on professional relationships; and administrative and workload impacts.

Emotional impacts

First, participants described significant emotional impacts on health practitioners from dealing with institutional objections, including frustration, anger and disgust, moral distress, and feeling stigmatised. A physician described feeling as if they had “failed” the patient who had a prolonged death after a forced transfer. Another physician discussed feeling outraged that their patient had experienced a series of forced transfers for assessments and provision:

“I was outraged by this one and I blew up. … Because we’re supposed to be all about patients and how is this possible?” (MAiD assessor/provider 17)

Another emotional impact on health professionals was stress from being subject to threats including complaints to various authorities, such as their professional regulatory body (College) and the police, and in one case, a death threat (Table 4). Participants indicated that although stressful, none of the complaints to the various authorities eventuated in sanctions.

Professional impacts

Second, participants discussed impacts on professional relationships caused by institutional objections, including employer-employee relationships. A key subtheme was situations involving a perceived conflict between the institution’s position and the views of staff. A number of participants described institutions with staff that were supportive of MAiD who did not agree with the institution’s position. For example:

“…most of the clinicians that I know who work in Catholic institutions would gladly provide MAiD, it’s just that they’re not empowered to. (MAiD assessor/provider 15)

As mentioned in Theme 1, the institutional position was often attributed to opposition by a key stakeholder such as a medical director or board of directors. Another professional impact was tensions with other health professionals, such as experiencing hostility and a lack of assistance in a facility from employees who appeared to share the institutional position.

Administrative and workload burdens

Third, health practitioners took on additional administrative and other workload burdens to navigate institutional objections. Some staff were allowed to participate in MAiD, but only in their own time and without institutional support. For example, a palliative care nurse whose employer did not support MAiD was informed they could participate but only outside work hours, and therefore unremunerated. Several participants describing having to scramble to find locations for their patients to receive MAiD assessments and/or provision. A nurse practitioner commented:

“The fact that she actually ended up having MAiD how she wanted in the community was a shit ton of work on my part and the connections that I had. I’m not saying that to toot my own horn. It literally was she just happened to be seen by the right person, and that’s sad.” (MAiD assessor/provider 1)

A MAiD assessor/provider in a rural area recounted that this additional workload was considerable because none of the local hospitals, hospices, or long-term care facilities would allow MAiD. The physician commented:

“… this is taking a lot of my time and mental head space I’d rather be spending on my kids than writing letters to CEOs of hospitals.” (MAiD assessor/provider 26)

Theme 6. catalysts for institutional change

A final theme was catalysts for institutional change. As noted in Theme 2, participants highlighted that in some (but not all) settings, institutional objections relaxed somewhat in the six years since Bill C-14 was passed, reducing negative impacts on patients.

“Those Catholic hospitals that at the beginning would never let you in the door, now they let you in the door to assess people.” (MAiD assessor/provider 21)

“I would say that 90% of [faith-based institutions in the province] are very, very supportive and they have now moved to allowing assessments but not provision. So there’s less and less feedback from patients and family about adversity within that setting.” (MAiD team member 5)

The position in non-faith based palliative care settings was reported to have changed more than in faith-based palliative care settings. A physician noted:

“… some of those facilities have now moved a little bit more towards the middle or even allow assessments and provisions to happen. Each of those facilities have found their level. … the whole spectrum exists in a hospice or palliative care facility. So there’s been a lot of movement in that community. Not so much in the religious based ones, though.” (MAiD assessor/provider 8)

Greater acceptance of MAiD over time

Participants attributed changes in institutional positions to a variety of catalysts. One prominent catalyst was greater acceptance of MAiD over time, due to positive patient experiences, growing comfort in the medical community, and destigmatization of MAiD. A physician commented:

“I think they [decision-makers in an objecting faith-based hospice] … were accustomed to seeing people suffer quite badly … they saw how humane MAiD was and how grateful the patients and the families were.” (MAiD assessor/provider 4)

Likewise, a physician in Ontario described how institutional change was prompted by individual patients seeking MAiD as an end-of-life choice:

“Those Catholic hospitals … now they let you in the door to assess people. So it’s changing because they recognise that this has become … a standard of practice and they need to get on board and give people options.” (MAiD assessor/provider 21)

Another related factor was growing comfort with MAiD in the medical community. This was driven in part by clinicians witnessing MAiD assessments and observing peers they respected engage in MAiD work. For example:

“Once they [other clinicians] experience it and they see how gentle and … the gift that you give a family with the provision and that opportunity, I don’t know, it’s hard to stay too closed about it for too long, at least in my experience.” (MAiD assessor/provider 3)

“Some of the palliative care doctors that were very opposed at the beginning are now the staunchest allies.” (MAiD assessor/provider 4)

Another participant noted that, as in other areas of social change, broader societal acceptance of MAiD has grown with time and experience, reducing stigma:

“As time has gone by and as society has come to understand – much in the way that when medical marijuana was legalized, society did not end. … They saw the same thing for abortion. … They saw the same thing for MAiD and people are understanding now that society didn’t end … time is a big thing. … Acceptance of the procedure and getting a sense that it is actually tremendously well-regulated … that there’s a process, that there’s due diligence, that there’s two assessments, that the person has to meet criteria, that this is overseen is an important thing as well. And then word of mouth, right … you don’t have to go too far before you meet someone who [has a relative that had MAiD] … it’s less taboo.” (MAiD team member 13)

Advocacy to promote patient access and address the harms of institutional objection

A second catalyst for change was advocacy to address the negative effects of institutional objection on patients. In addition to mitigating harm on an individual patient (discussed in Theme 4), advocacy for individual patients also contributed to broader institutional change. Advocacy was undertaken by patients, family caregivers, MAiD assessors/providers, and organizations such as Dying with Dignity Canada and CAMAP. A physician commented on the important role of on-the-ground advocacy by patients and clinicians:

… between the patients driving it on one end and the clinicians who are in the community itself driving it – that’s what causes change in this country, those two forces.” (MAiD assessor/provider 8)

Advocacy was particularly effective when amplified by media reports. For example, a physician recounted how media attention on a particular case impacted an institution’s discretion:

“… I talked to the family, and they said “Oh, yes, we’re going to the press” … we went to the press that this poor man had to be transported … this was outrageous and awful. And guess what, ever since then every single patient at that facility has been assessed as requiring an in-hospital assessment [as opposed to being transferred off site].” (MAiD assessor/provider 22)

Education and relationship building

A third catalyst was education and relationship building with objecting institutions. Participants highlighted proactive work by MAiD teams in some health authorities, who met with institutional decision-makers and staff. For example:

“… I think the upfront work that the health authority did … [they] did a really good job of doing a lot of background institutional work and meeting with the nurses, the nurse practitioners, the long-term care workers.” (MAiD assessor/provider 12)

Individual MAiD assessors/providers also described participating in education and relationship building, through speaking with staff in objecting institutions about what the MAiD process entailed and the impacts of transfers.

Institutional dynamics

Institutional dynamics were another catalyst for institutional change. Participants described how greater acceptance over time by clinicians within an institution contributed to changes in institutional policy. For example, a physician described how attitudes changed towards MAiD in a hospice that allowed external assessors to provide MAiD assessments:

“I could go in there, do an assessment, speak to a patient, leave. I would come in almost like a specialist. … I followed the rules happily, respected each other, did the work. It went from that, which it stayed at for a couple of years. Then of course the inevitable, which happens all the time. The palliative care doctors … they’re the most patient centred doctors on the planet, they are very attached to some of their patients, they’ve known them for a while, they’re quite connected, they work hard with them, and those patients start begging them for help and they start asking them for assisted deaths. Some of those clinicians started feeling like … this is my patient, I can help this patient. So they started to want to – there is that one case, like this one I’m going to support. So they’d asked me and I showed them how to do the assessment form then they would do it. Then they would only do it maybe once or twice a year, and then all of a sudden they’re like, well I can do this, this patient of ours, I can do it. All of a sudden we’ve got now maybe half of them are willing to do assessments.” (MAiD assessor/provider 8)

Participants also cited leadership by dedicated individuals and support from staff or clinicians at various levels within an institution who supported MAiD access. Participants discussed champions in organisations, such as medical directors, who developed policy to support MAiD, and decisions by boards or CEOs to support MAiD (or establish processes to foster patient-centred care). For example:

“I met with the CEO of the hospital. … I had [CEO] behind me, he said ‘Yeah, this is – let me be clear, this is happening at this hospital, and it happens the way it needs to happen and that’s all there is to it.’ Obviously, there were political pieces that had to be done very carefully…” (MAiD assessor/provider 9).

Regulatory mechanisms and health system structures

Finally, some participants cited the role of regulation and health system structures in fostering institutional change. This included government policy and agreements, and policy set by MAiD teams in some areas. For example, a MAiD team member noted:

… this health authority and [names of key leads] and the director at the time were very clear about access to care.” (MAiD team member 5)

Another MAiD team member noted the importance of the provincial regulatory framework in British Columbia, which required long term and residential aged care facilities to provide information about MAiD:

“The provincial government did say quite clearly that information is to be made easily accessible to all residents in these facilities. So they’re not allowed to restrict information access.” (MAiD team member 8)

Similarly, participants from Nova Scotia described how an objecting hospital’s position changed through the negotiation of a separate space attached to the hospital that persons could use for MAiD. This was achieved through advocacy by several key regulatory stakeholders.

Participants perceived that the absence of more formal regulatory mechanisms and top-down decision-making in fostering system change resulted in insufficient protection for patients from institutional objections. Despite descriptions of strong support by higher authorities in some locations, in others, participants felt that the regulatory environment still lacked sufficient protection for patients. For example:

“I wish the Ontario government would say ‘No, you will all provide’ … You get a dollar of our money, then you will provide all services…” (MAiD assessor/provider 26).

Similarly, a participant from British Columbia noted that government agreements would need to be amended to make changes:

“… in some provinces like the one that I’m in, there is actually a contractual agreement from the ‘90s that allows faith-based facilities to dictate what happens on the premise. So we probably can’t break that contract or it needs to be re-looked at.” (MAiD assessor/provider 8)

However, some participants acknowledged that this and other government-led change was highly political: I can understand why the politicians don’t want to touch it… (MAiD team member 8).

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